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HUGHES' 

COMPEND  OF  PRACTICE 


PHYSICIANS'  EDITION. 


TO   PHYSICIANS. 

The  several  essential  qualities  which  a  good  Visiting 
List  should  possess  are,  compactness,  convenience 
of  arrangement,  and  strength  to  resist  the  unusual 
hard  wear  it  receives.  These  qualities  are  all  com- 
bined in  Lindsay  &:  Blakiston's  Physicians'  Visiting 
List,  which  has  now  been  published  for  forty-one 
years,  and  no  better  evidence  of  the  practical  worth 
of  this  book  can  be  offered  than  the  uniform  increase 
in  popularity  it  has  enjoyed  with  each  successive  issue. 
One  of  its  chief  features  is  its  size ;  it  measures 
6J^  X  3j^  inches,  and  the  smallest  size  weighs  but  t,}4 
ounces  and  is  only  ^  of  an  inch  thick.  The  large 
sizes  are  a  little  thicker  and  heavier;  it  is,  however, 
the  smallest  and  lightest  Visiting  List  published. 
Our  many  years'  experience  has  enabled  us  to  put  it 
together  in  the  best  manner,  and  to  add  many  im- 
provements during  the  past  few  years.  It  is  arranged 
for  25,  50,  75  and  100  patients  per  day  or  week,  inter- 
leaved and  plain,  dated,  undated  and  monthly.  Prices 
range  from  75  cents  to  $3.  Complete  circular  will 
be  sent  you  upon  application.  P.  Blakiston,  Son 
&  Co.,  Medical  Publishers  and  Booksellers,  1012 
Walnut  Street,  Philadelphia. 


COMPEND 


OF   THE 


PRACTICE  OF  MEDICINE. 


BY 


DAN'L    E.  HUGHES,  M.D., 

CHIEF   RESIDENT    PHYSICIAN    PHILADELPHIA    HOSPITAL  ; 

LATE    DEMONSTRATOR   OF    CLINICAL   MEDICINE   IN   THE   JEFFERSON   MEDICAL    COLLEGE 

OF    PHILADELPHIA;    FELLOW    OF   THE    COLLEGE    OF    PHYSICIANS 

OF   PHILADELPHIA,  ETC. 


PHYSICIANS'  EDITION. 


THOROUGHLY  REVISED  AND  ENLARGED. 
BASED  ON  THE  FOURTH   REVISION  OF   THE   QUIZ-COMPEND   EDITION 

AND 

INCLUDING  A  VERY  COMPLETE  SECTION  ON  SKIN  DISEASES. 


PHILADELPHIA: 

P.  BLAKISTON,  SON  &  CO., 

No.   IOI2  Walnut  Street. 
1892. 


)rti 


Copyright,  1889,  by  P.  Blakiston,  Son  &  Co. 


Pbesb  of  Wm.  F.  Fell  &  Co., 
1220-24  Sanbom  Sr., 

PHILADELPHIA 


TO 

HIS  ESTEEMED  FRIEND  AND  TEACHER, 

J.  M.  DA  COSTA,  M.D., 

Professor  of  the  Practice  of  Medicine 

IN  the 

Jefferson  Medical  College, 

THIS  WORK 

IS  RESPECTFULLY  DEDICATED  BY 

THE  AUTHOR. 


PREFACE 

TO 

THE  PHYSICIANS'  EDITION. 


The  favor  with  which  the  "  Compends  of  the  Practice  of  Medicine," 
as  pubhshed  in  the  Quiz-Compend  series,  have  been  received,  together 
with  the  knowledge  that  many  practitioners  have  made  use  of  them, 
suggested  the  advisabihty  of  preparing  an  edition  especially  for  Physi- 
cians. To  that  end  the  Compends  have  been  thoroughly  revised  and 
enlarged,  by  the  incorporation  of  the  more  recent  improvements  in 
practice  and  the  addition  of  a  very  complete  section  upon  Diseases  of 
the  Skin,  which,  with  the  addition  of  a  complete  index,  and  its  publi- 
cation in  one  volume,  renders  it  much  more  convenient  for  reference. 

The  exceptional  character  of  the  advantages  afforded  the  Author 
for  clinical  work,  as  Demonstrator  of  CKnical  Medicine  in  the  Jeffer- 
son Medical  College,  and  also  as  Assistant-in-charge  of  the  Medical 
Dispensary  of  the  College  Hospital  for  a  number  of  years,  together 
with  his  system  of  notes  employed  in  the  Quiz-room  during  the  past 
five  years,  have  formed  the  basis  of  this  Compend,  which  may  there- 
fore be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine. 

Free  reference  has  been  made  to  the  latest  writings  and  teachings 
of  Professors  Da  Costa,  Bartholow,  Pepper,  Fhnt,  Loomis,  Reynolds, 
Duhring,  Fred.  T.  Roberts  and  others,  to  whom  acknowledgment  is 
here  made. 

DANIEL  E.  HUGHES. 


PREFACE  TO  FOURTH  EDITION. 


The  rapid  sale  of  the  previous  editions  of  this  book  has  encouraged 
the  author  to  make  a  very  complete  revision  for  the  fourth  edition. 
This  has  necessitated  the  rewriting  of  many  sections  and  a  slight 
enlargement  of  the  work,  so  as  to  include  all  new  methods  and  dis- 
coveries in  Diagnosis,  Pathology  and  Treatment.  Every  effort  has 
been  made  to  keep  it  as  compact  as  is  compatible  with  clearness,  and 
to  make  it  a  thorough  guide  to  the  practice  of  medicine. 

D.  E.  H. 


CONTENTS. 


PAGE 

INTRODUCTION, 9 

FEVERS, 14 

Continued, 16 

Periodical, 30 

Eruptive, 3g 

DISEASES  OF  THE  MOUTH, 52 

DISEASES  OF  THE  STOMACH, 58 

DISEASES  OF  THE  INTESTINAL  CANAL, 72 

INTESTINAL  PARASITES, 98 

DISEASES  OF  THE  PERITONEUM, 102 

DISEASES  OF  THE  BILIARY  PASSAGES, 107 

DISEASES  OF  THE  LIVER, no 

DISEASES  OF  THE  KIDNEYS, 118 

ACUTE  GENERAL  DISEASES, 143 

DISEASES  OF  THE  RESPIRATORY  SYSTEM,     174 

DISEASES  OF  THE  NASAL  PASSAGES, 193 

DISEASES  OF  THE  PHARYNX 198 

DISEASES  OF  THE  LARYNX, 203 

DISEASES  OF  THE  BRONCHIAL  TUBES, 216 

DISEASES  OF  THE  LUNGS, 238 

DISEASES  OF  THE  PLEURA, 261 

DISEASES  OF  THE  CIRCULATORY  SYSTEM, 268 

DISEASES  OF  THE  NERVOUS  SYSTEM, 297 

DISEASES  OF  THE  SPINAL  CORD, 33^ 

CEREBRO-SPINAL  NEUROSES, 346 

DISEASES  OF  THE  NERVES, 357 

DISEASES  OF  THE  BLOOD, 362 

DISEASES  OF  THE  SKIN 37^ 

INDEX, 449 

viii 


COMPEND 


OF   THE 


PRACTICE  OF  MEDICINE. 


INTRODUCTION. 

The  Principles  of  Medicine  constitute  what  may  be  termed 
Medical  Scze?tce. 

The  Practice  of  Medicine  is  the  exercise  of  medical  art,  and 
embraces  all  that  pertains  to  the  knowledge  of,  prevention  and  cure 
of,  the  diseases  which  the  physician  is  called  upon  to  treat. 

Disease  may  be  defined  as  a  deviation  or  alteration  in  the  func- 
tions, properties  or  structure  of  some  tissue  or  organ,  whereby  its 
office  is  no  longer  performed  in  accordance  with  the  natural  standard  : 
Organic  disease,  when^  associated  with  an  organic  change  in  the  af- 
fected part ;  Functional  disease,  when  the  phenomena  are  indepen- 
dent of  any  apparent  structural  lesion. 

The  study  of  disease,  whether  organic  or  functional  in  character, 
is  termed  Pathology. 

Pathology  explains  the  origin,  causes,  clinical  history  and  nature 
of  the  various  morbid  conditions  to  which  the  economy  is  liable. 

The  study  of  individual  diseases  constitutes  Special  Pathology; 
while  the  study  of  the  morbid  conditions  common  to  a  greater  or  less 
number  of  diseases,  constitutes  General  Pathology. 

Nomenclature,  or  the  naming  of  diseases,  is  a  subdivision  of  gen- 
eral pathology.  The  value  of  nomenclature  as  applied  to  disease  is 
I  9 


10       '  PRACTICE   OF   MEDICINE. 

that  the  name  chosen  shall  express  the  morbid  condition  involved,  as 
well  as  its  location. 

If  the  morbid  condition  be  an  inflammation,  the  suffix  itis  is  added 
to  the  anatomical  name  of  the  part  affected ;  thus,  if  the  disease  be 
an  inflammation  of  the  peritoneum,  it  is  n2im.tdi  peritonitis. 

If  the  morbid  condition  is  catarrhal,  Buch  as  a  transudation  or  flux, 
the  liquid  escaping  upon  a  mucous  surface,  the  suffix  rhcea  is  used  ; 
thus,  a  catarrhal  inflammation  of  the  intestinal  tract  is  termed  diar- 
rhcea  2in&  enteror/icea. 

If  the  morbid  condition  be  a  flow  of  blood  or  hemorrhage  from  a 
mucous  surface,  the  suffix  rhagia  is  used  ;  thus,  a  hemorrhage  from 
the  small  intestines  is  termed  enterorhagia. 

If  the  morbid  condition  be  pain  without  inflammation,  the  suffix 
a/gia  is  used.  The  various  forms  of  neuralgias  being  an  example  ; 
thus,  neuralgia  of  the  stomach  is  \.evm.td  gastralgia. 

If  the  morbid  condition  be  in  the  blood,  the  suffix  cB7nia  is  used. 
Thus,  AncEmia  is  impoverishment  of  the  blood;  Urcsmia,  the  morbid 
accumulation  of  urea  in  the  blood ;  SepticiEmia,  putrid  infection  of 
the  blood ;  Pyamia,  purulent  infection  of  the  blood. 

If  the  morbid  condition  is  in  the  urine,  the  ending  uria  is  used  to 
indicate  it.  Albinni7iuria,  when  albumin  in  the  urine ;  Hcematiina, 
when  blood  in  the  urine ;  Oxaluria,  when  oxalates  occur  in  the  urine. 

If  the  morbid  condition  be  a  dropsical  affection,  the  prefix  hydro  is 
added  to  the  part  affected.  Thus,  a  dropsical  accumulation  in  the 
peritoneum  is  termed  hydro-peritoneinn. 

If  the  morbid  condition  be  that  of  air  in  an  unnatural  part,  the 
^r^^x  p7teumo  to  the  name  of  the  part  is  used,  as  in  pjteumo-pericar- 
dium. 

If  the  morbid  condition  be  an  inflammation  of  the  membrane 
investing  the  part  inflamed,  the  prefix  peri  is  made  use  of.  Thus, 
for  an  inflammation  of  the  investing  membrane  of  the  kidney  the 
term  is  perinephritis. 

Inflammation  of  the  connective  tissue  surrounding  an  organ  is 
designated  by  the  ^^xg-^x  para.  Thus,  /ara;«<?/r?//^  for  inflammation 
of  the  connective  tissue  about  the  womb. 

A  termination  in  oma  signifies  a  tumor,  as  in  sarco?na  or  carcinoma. 

The  s\\^\  pathy  is  used  to  designate  a  morbid  condition  of  a  part, 
without  indicating  its  particular  character,  an  example  being  the  use 
of  the  term  encephalopathy. 


INTRODUCTION.  H 

Morbid  Anatomy  is  the  study  of  the  changes  in  the  tissues  and 
fluids  of  the  body  appreciable  to  the  naked  eye  or  with  the  aid  of  the 
microscope. 

Histolog'y  is  the  study  of  the  minute  anatomy  ot  the  tissues  and 
fluids  of  the  body  with  the  microscope. 

Pathogenesis  is  the  study  of  the  origin  and  development  of 
pathological  processes, 

Lesions  are  appreciable  anatomical  changes. 

Etiology  is  that  subdivision  of  general  pathology  which  treats  of 
the  causes  of  disease.  The  knowledge  of  the  cause  of  any  morbid 
action  is  of  value  in  the  prevention,  management  and  removal  of 
disease. 

The  Causes  of  disease  may  be  divided  into  internal,  external, 
ordijiary,  specific,  prijnary,  secondary,  predisposing  and  exciting. 

Examples  of  ifiternal  or  intrinsic  causes  are  those  having  their 
origin  in  the  m.ind,  such  as  prolonged  mental  application,  intense  or 
long-continued  emotional  excitement,  long-continued  mental  depres- 
sion and  the  possession  of  and  concentration  upon  a  predominant 
idea.  Other  examples  are  the  accumulation  of  certain  products  in  the 
blood,  such  as  urea,  uric  or  lactic  acid. 

External  ox  extrinsic  causes  are  such  as  infectious  miasms,  viruses, 
poisons,  wounds  and  injuries. 

An  ordinary  cause  is  one  to  which  all  are  more  or  less  exposed  ;  to 
wit,  atmospherical  changes. 

Specifix  or  special  causes  are  those  producing  a  distinct  and  specific 
disease,  such  as  the  special  cause  of  typhoid  fever,  yellow  fever, 
smallpox  and  cholera. 

A  contagious  disease  is  one  due  to  a  special  cause,  whose  causative 
agent  is  a  specific  poison  that,  introduced  into  the  body  of  another, 
will  give  rise  to  the  same  disease.  An  infectious  disease  is  also  due  to 
a  special  cause  that  under  certain  conditions  is  capable  of  unlimited 
increase  or  multiplication.  An  infectious  disease  may  or  may  not  be 
contagious. 

An  example  of  z.  primary  cause  is  any  external  traumatic  cause. 

A  secondary  cause  is  well  seen  in  the  secondary  pericarditis  result- 
ing from  an  accumulation  of  urea  in  the  blood.  The  retention  of  the 
urea  in  the  blood  being  due  to  a  diseased  kidney. 

A  predisposition  to  disease  is  a  special  liability  or  susceptibility  to 
its  occurrence,  and  may  be  either  inherited  or  acquired. 


12  PRACTICE   OF   MEDICINE. 

Inherited  or  constitutional  predisposition  to  certain  diseases  is  also 
termed  Diathesis  ;  an  example  is  in  the  offspring  of  phthisical  parents, 
who  are  said  to  be  of  a  phthisical  diathesis. 

Acquired  predisposition  is  such  as  arises  from — 

I.  Habits,  to  wit:  Strain  upon  the  nervous  system  resulting  in 

nervous  diseases. 

II.  Age,  to  wit :  Children  are  very  liable  to  catarrhal  disorders. 

Young  adults,  to  fevers  and  perverted  sexual  disorders. 
Middle  age,  to  heart,  kidney  and  digestive  disorders  and 

cancer. 
Old  age,  to  degeneration  of  the  heart  and  vessels. 

III.  Occupation,  to  wit :  Miners,  weavers  and  cutlers,  lung  dis- 

eases. 

IV.  Sex,  to  wit:  Women,  emotional  nervous  diseases. 
Men,  as  more  exposed,  rheumatism  and  pneumonia. 

V.  Race,  to  wit :  Negro,  phthisis  and  scrofula :  exempt  from 

malaria. 

Exciting  causes  are  those  giving  rise  to  morbid  conditions  in  those 
already  predisposed  to  certain  diseases,  but  lacking  the  action  which 
determines  their  occurrence ;  to  wit :  Persons  predisposed  to  acute 
rheumatism,  on  being  exposed  to  certain  atmospheric  changes  have 
an  attack ;  fear  has  produced  chorea ;  anger  has  caused  jaundice  ; 
worry  has  produced  cardiac  troubles. 

The  Clinical  History  of  disease  includes  all  the  symptoms  and 
signs  which  may  occur  from  the  period  of  ittcubation  until  its  final 
terjnination. 

Symptoms  and  Signs  are  such  alterations  in  the  healthy  func- 
tions as  give  evidence  of  the  existence  of  a  diseased  condition  or  per- 
verted function,  and  may  be  either  objective  or  subjective.  Objective 
when  evident  to  the  senses  of  the  observer,  such  as  redness  or  swell- 
ing.     Subjective,  when  felt  by  the  patient,  such  as  pain  or  numbness. 

The  Period  of  Incubation  is  that  interval  between  the  entrance 
of  the  poison  into  the  system  and  its  manifestation,  and  seldom  pre- 
sents recognizable  symptoms. 

The  Prodromes  are  the  earliest  recognizable  symptoms  ;  as  the 
rigors  or  chills  during  the  invasion  of  fever,  and  the  various  aura  pre- 
ceding an  epileptic  fit. 

An  acute  disease  is  one  in  which  the  invasion  is  sudden  and  rapid, 
and  as  a  rule  severe ;  when  the  symptoms  develop  less  rapidly  and 


INTRODUCTION.  13 

are  less  intense  the  disease  is  said  to  be  sub- acute ;  when  gradual 
or  slow  in  development,  duration  and  intensity  the  disease  is  said 
to  be  cJironic.  It  must  be  borne  in  mind,  however,  that  there 
may  be  disturbed  action  in  every  intermediate  degree  between  these 
extremes. 

Pathognomonic  is  the  term  applied  to  such  symptoms  as  belong 
to  one  particular  disease,  and  are  therefore  characteristic  of  it,  to  wit : 
the  rusty  sputum  of  pneumonia. 

Physical  Signs  are,  strictly  speaking,  objective  symptoms. 
The  Termination  of  a  diseased  action  may  occur  in  one  of  three 
ways,  to  wit :   Cure,  Secondary  Process,  or  in  Death. 
Cure  may  occur  by — 

I.  Lysis,  or  slow  return  to  health. 

II.   Crisis,  abrupt  termination,  usually  with  a  critical  discharge. 
III.  Metastasis,  or  changing  from  one  location  to  another. 
Secondary  processes  is  when  the  diseased  action  is  substituted  by 
a  new  morbid  process,  to  wit :  Rheumatism  followed  by  endocarditis  ; 
apoplexy  by  cerebral  softening. 

By  DeatJi  is  meant  a  complete  cessation  of  tissue  change  occurring  by 
I.  Asthenia,  or  an  ever  increasing  debility,  to  wit :  phthisis, 
cancer,  Bright's  disease. 
II.  AncBinia,  or  insufficient  quantity  or  quality  of  blood. 

III.  Apnoea  or  non-aeration  of  blood,  to  wit :  acute  lung  dis- 

eases, or  croup, 

IV.  Coma,   death   beginning   at  the   brain,  to   wit :    ursemia, 

narcotic  poisoning,  cerebral  hemorrhage. 

Diagnosis  of  disease,,  or  the  discrimination  of  diseases,  implies  a 
complete,  exact  and  comprehensive  knowledge  of  the  case  under 
consideration,  as  regards  the  origin,  seat,  extent  and  nature  of  all  its 
morbid  conditions. 

A  direct  diagnosis  is  made  when  the  morbid  condition  is  revealed 
by  a  combination  of  clinical  phenomena,  or  some  one  or  more 
pathognomonic  symptoms. 

A  differential  diagnosis  is  the  result  when  the  diseases  resembling 
each  other  are  called  to  mind  and  eliminated  from  each  other. 

A  diagnosis  by  exclusion  is  by  proving  the  absence  of  all  diseases 
which  might  give  rise  to  the  symptoms  observed,  except  one,  the  pres- 
ence of  which  is  not  actually  indicated  by  any  positive  symptoms. 

Prognosis  of  disease  is  the  ability  or  knowledge  to  foretell  the 


14    -  PRACTICE    OF    MEDICINE. 

most  probable  result  of  the  condition  present,  and  involves  an  amount 
of  tact  or  knowledge  only  acquired  by  prolonged  clinical  experience. 

Treatment.  The  ultimate  and  most  important  object  of  the 
study  of  medicine,  from  a  practical  point  of  view,  is  to  learn  how  to 
cure,  relieve,  or  prevent  disease,  and  it  must  be  borne  in  mind  that 
this  does  not  consist  solely  in  the  administration  of  drugs,  but  requires 
strict  faithful  attention  to  diet  and  hygie?te. 

When  the  object  is  to  prevent  disease,  such  as  smallpox  by  vaccina- 
ation,  it  is  called  Prophylactic  or  Preventive  treatment. 

When  disease  is  to  be  broken  up,  although  already  begun,  such  as 
aborting  the  chill  of  malaria,  it  is  called  the  Abortive  treatment. 

When  the  disease  is  allowed  to  run  its  natural  course  without 
attempting  its  removal,  but  being  constantly  on  the  alert  for  obstacles 
to  its  successful  issue,  such  as  the  generally  adopted  plan  of  treating 
continued  fevers,  it  is  called  Expectant  treatment. 

When  the  disease  is  incurable,  and  removal  of  marked  suffering  is 
the  object,  it  is  called  /l?//m//2/^  treatment. 

When  marked  weakness  and  prostration  are  to  be  overcome,  it  is 
called  Restorative  treatment. 


FEVERS. 


Fever  is  a  condition  in  which  there  are  present  the  phenomena 
of  rise  of  teinperature,  quickened  circulation,  marked  tissue  change 
and  disordered  secretion. 

The  primary  cause  of  the  fever  phenomena  is  a  disorder  of  the 
sympathetic  nervous  system  giving  rise  to  disturbances  of  the  vaso- 
motor filaments. 

Rise  of  temperatnre  is  the  preeminent  feature  of  all  fevers,  and 
can  only  be  positively  determined  by  the  use  of  the  clinical  ther- 
mometer. The  Xcrxn  feverishftess  is  used  when  the  temperature  ranges 
from  ()(f  to  ioo°  Fahr. ;  slight  fever  if  ioo°  or  ioi°  ;  moderate,  102°  or 
103°;  high  if  104°  or  105'^ ;  and  ititense  if  it  exceed  the  latter. 

Quickened  circulation  is  the  rule  in  fevers,  the  frequency  usually 
maintaining  a  fair  ratio  with  the  increase  of  the  temperature.  A  rise 
of  one  degree  Fahr.  is  usually  attended  with  an  increase  of  eight  to 
ten  beats  of  the  pulse  per  minute. 


FEVERS.  15 

The  following  table  gives  a  fair  comparison  between  temperature 
and  pulse : — 

A  temperature  of  98°  F.  corresponds  to  a  pulse  of  60 

((  a  pgO  Y,  "  "  "  70 

"  "  ioo°  F.  "  "  "  80 

"  "  101°  F.  "  "  "  90 

<<  u  J020  F.  "  "  *'  100 

"  "  103°  F.  "  "  "  1 10 

«  "  104°  F.  "  "  "  120 

«  i(  iQ^o  jr^  «<  «  «  j^o 

"     "  106°  F.     "  "     "  140 

TA^  tissue  waste  \s  marked  in  proportion  to  the  severity  and  dura- 
tion of  the  febrile  phenomena,  being  slight  or  nil  in  febricula,  and 
excessive  in  typhoid  fever. 

The  disordered  secretions  are  manifested  by  the  deficiency  in  the 
salivary,  gastric,  intestinal  and  nephritic  secretions,  the  tongue  being 
furred,  the  mouth  clammy,  and  there  occurring  anorexia,  thirst,  con- 
stipation, and  scanty,  high-colored,  acid  urine. 

An  Idiopathic  or  Essential  fever  is  one  in  which  no  local  affec- 
tion causes  the  fever  phenomena,  although  lesions  may  arise  during 
its  progress. 

A  Symptomatic  or  Secondary  fever  is  one  dependent  upon 
an  acute  inflammation. 

GENERAL  TREATMENT  OF  FEVERS. 

1.  Reduce  the  temperature.  The  cold  bath  or  cold  pack  will  do 
this  most  decidedly,  but  entails  much  labor  and  is  not  altogether  free 
from  danger,  and  so  its  use  is  advised  only  in  severe  cases.  Cool 
sponging  is  of  decided  advantage.  Quinina,  in  gr.  xx  doses  repeated, 
is  usually  reliable.  Aiitipyrine ,  gr.  xx  repeated  and  antifebrin  gr.  x-xv 
repeated,  are  also  recommended. 

2.  Lessen  the  circulation.  If  the  pulse  be  full,  strong  and  rapid, 
use  aconitwn.  If  the  circulation  be  weak,  stiinulajits  with  digitalis 
or  caffeina,  are  indicated. 

3.  Attend  to  the  secretions.  Remove  the  waste  of  the  tissues  by 
diuretics,  diaphoretics,  and,  if  particularly  indicated,  laxatives.  It  is 
better  for  every  fever  that  the  skin  should  be  moist,  than  that  it  should 
be  harsh  and  dry.  It  is  better  that  the  urine  should  be  abundant, 
than  that  it  should  be  scantv  and  thick  with  tissue  waste.     Watch  the 


16    ,  PRACTICE   OF   MEDICINE. 

Stools,  that  you  may  judge  whether  the  food,  be  it  soHd  or  hquid,  is 
being  digested.  The  free  use  of  water  is  beneficial  in  promoting  the 
various  secretions. 

4.  Nourish  the  patient.  "  Don't  starve  a  fever."  Administer  milk, 
beef-tea,  and  other  light  nutritious  food,  in  small  quantities,  but  at 
frequent  intervals. 

5.  Watch  the  nursing.  Much  of  the  success  in  the  management  of 
fever  patients  can  be  attributed  to  good  sensible  nursing.  Through  it 
are  secured  the  five  important  essentials  of  every  sick  room  ;  to  wit : 
cleanhness,  cheerfulness,  regularity,  ventilation  and  light. 

CONTINUED  FEVERS. 

All  continued  fevers  are  characterized  by  a  steady  progress  of  the 
febrile  movernent,  without  either  a  too  decided  rise  or  fall  in  the  tem- 
perature to  modify  the  impression  of  a  continuous  action. 

SIMPLE  CONTINUED  FEVER. 

Synonyms.  Irritative  fever ;  febricula ;  ephemeral  fever ;  synocha. 

Definition.  A  continued  fever,  of  short  duration,  mild  in  charac- 
ter, not  the  result  of  a  specific  poison,  rarely  fatal,  but  when  death 
does  occur,  presenting  no  characteristic  lesion. 

Causes.  Fatigue,  mental  and  physical ;  exposure  to  the  sun, 
great  heat  or  cold  ;  excesses  in  eating  and  drinking  ;  excitement  and 
violent  emotion.  Most  common  in  childhood.  It  is  not  a  miasmatic 
fever,  neither  is  it  contagious. 

Symptoms.  Onset  sudden  with  an  abrupt  feeling  of  lassitude, 
followed  by  a  decided  chill  or  chilliness,  a  sudden  and  rapid  rise  of 
tefnperature,  quick  tense  pulse,  headache,  dry  skin,  great  thirst,  coated 
tongue,  costive  bowels,  and  scafity  high-colored  uri7ie.  Cases  due  to 
errors  in  diet  are  accompanied  by  nausea  and  voiniting.  Attacks 
occurring  during  childhood,  due  to  excitement,  fright  or  the  emotions, 
may  be  associated  with  convulsions.  The  temperature  may  within  an 
hour  or  two  reach  103°  F,,  or  more,  when  slight  deliriicm  may  occur. 
The  affection  has  no  constant  or  characteristic  eruption. 

Duration.     From  twenty-four  hours  to  six  or  seven  days. 

Termination.  Usually  within  a  few  hours,  to  a  day  or  two,  the 
temperature  rapidly  falls  to  the  norm,  an  instance  oi  crisis ;  or  it  may 
continue  for  several  days  gradually  falling  to  the  r\oxvi\{lysis^.  Herpes 


FEVERS.  17 

about  the  lips  and  nostrils  are  often  observed  at  the  close  of  an  attack. 
Convalescence  is  rapid. 

Diagnosis.  Unless  the  fever  can  be  attributed  to  some  one  of  the 
causes  that  give  rise  to  it,  a  doubt  as  to  its  character  may  exist  for  the 
first  twenty-four  hours,  after  which  time  it  can  hardly  be  mistaken  for 
any  other  disease. 

The  following  is  a  familiar  instance  in  this  affection.  A  child,  apparently 
in  the  best  of  health,  is  at  play,  or.  may  be  at  school,  suddenly  complains  of 
nausea  and  may  vomit,  the  skin  becoming  hot,  dry  and  flushed  or  soon  covered 
with  an  erythematous  rash,  the  pulse  is  quick  and  tense,  there  is  headache, 
pains  in  the  limbs,  and  great  fretfulness  or  nervousness.  The  axillary  tempera- 
ture may  reach  I02°-I04°  F.  The  whole  aspect  is  most  alarming,  when  a 
laxative  is  administered,  the  surface  sponged  with  a  tepid  lodon,  sleep  follows 
during  which  there  may  be  free  perspiration,  and  the  following  day  the  child  is 
and  continues  perfectly  well. 

Prognosis.     Recovery,  without  sequelae,  the  rule. 

Treatment.  Very  little  medicine.  Rest  in  bed.  A  full  dose  of 
hydrargyri  chloridiun  mite,  or  an  e7iema,  sp07iging  the  surface  with 
.cold  or  tepid  water,  and  the  administration  of  salme  diaphoretics  and 
diuretics.  If  there  is  great  arterial  excitement  aconitum  may  be 
added.  Light  liquid  diet  is  most  agreeable.  Cases  in  which  the 
nervous  symptoms  are  prominent  do  well  on  Fothergill's  "  fever  mix- 
ture of  the  future,"  to  wit: — 

U.     Acid,  hydrobrom., f.^ss-j 

Syr.  simplicis, .     .  {"2^  ss-j 

Aquae, f^ij-iij.         M. 

SiG. — Every  four  hours. 
QuinificB  sulphas  in  tonic  doses  during  convalescence. 

CATARRHAL  FEVER. 

Synonyms.  Influenza;  epidemic  catarrhal  fever;  contagious 
catarrh. 

Definition.  A  continued  fever,  occurring  generally  as  an  epi- 
demic;  due  to  a  specific  cause;  characterized  by  a  catarrhal  inflam- 
mation of  the  respiratory  organs,  and  sometimes  of  the  digestive, 
always  accompanied  by  nervous  phenomena  and  a  debility  out  of 
proportion  to  the  intensity  of  the  fever  and  the  catarrhal  processes. 
During  the  prevalence  of  an  epidemic  animals  suffer  more  than  man. 

Causes.     A  specific  vegetable  gerui,  uninfluenced  by  soil,  climate 


18     •  PRACTICE    OF    MEDICINE. 

or  atmospheric  changes.     It  is  not  contagious.     One  attack  does  not 
give  immunity  from  another  attack,  but  rather  predisposes  to  it. 

Symptoms.  The  clinical  history  of  this  disease  presents  the 
greatest  variations  as  regards  intensity,  from  the  most  trifling  indis- 
position in  one,  to  an  illness  of  the  gravest  kind,  terminating  in 
death,  in  another. 

The  onset  is  sudden,  with  a  ^//z7/ followed  hy  fever,  the  temperature 
reaching  ioi°  to  103°,  a  quick,  compressible  pulse,  and  severe  sJiooting 
pai?is  in  the  eyes,  frontal  sinuses,  joints  and  muscles.  The  chill  and 
fever  are  rapidly  followed  by  chilliness  along  the  spijie,  pain  in  the 
throat,  hoarseness,  deafness,  coryza,  sneezing,  injected,  watery  eye, 
and  a  dry,  irritative,  laryngeal  cough,  sometimes  becoming  ^r^«r/!za/. 
The  tongue  is  furred,  there  is  anorexia,  epigastric  distress,  nausea, 
vomiting,  and  oftentimes  diarrhcea.  In  some  epidemics  the  digestive 
symptoms  are  the  most  prominent,  when  dysentery  may  occur. 

The  above  symptoms  are  always  associated  with  decided  weakness 
and  debility  altogether  out  of  proportion  to  the  intensity  of  the  fever 
and  the  catarrhal  phenomena.  Delirium  is  rare,  but  marked  hebetude 
and  cutaneous  hypercssthesia  are  common. 

Duration.  Four  to  seven  days,  with  protracted  convalescence. 
Relapses  frequently  occur. 

Complications.  Lobar  or  catarrhal  pneumonia  frequently  occur, 
which  adds  to  the  gravity  of  the  attack.  The  cough  may  outlast  the 
disease  several  weeks. 

Diag"nosis.  Isolated  cases  maybe  mistaken  for  a  "bad  cold." 
But  when  epidemic,  the  sudden  onset,  7narked  general  catarrh  and 
decided  prostration,  should  prevent  error. 

Prognosis.  Recovery  is  the  rule  when  it  occurs  in  the  healthy 
and  vigorous.  Grave  when  the  very  young,  very  old,  or  those  suffer- 
ing from  organic  disease,  such  as  Bright's  disease,  fatty  heart,  or 
emphysema,  are  attacked. 

Treatment.  No  specific.  Support  the  system  and  treat  indica- 
tions. All  measures,  of  whatever  kind,  that  tend  to  depress  the  gen- 
eral nervous  system,  or  the  functional  activity  of  the  respiration,  and 
especially  the  heart-power,  are  to  be  avoided.  The  catarrh,  pains 
and  cough  are  at  least  ameliorated  by  the  following  : — 

\\.     Pulvis  ipecacuanhae  et  opii, g''- v 

I'otassii  nitrat., gr-  v. 

Every  three  hours. 


FEVERS.  19 

Or— 

R .     Quininaesulph,,  .    .    ' grs.  ij-iv 

Morphinae  sulph., g'"-  tV 

Aqu£e  lauro-cerasi, 3J.  M. 

SiG. — Every  four  hours. 

The  frequent  inhalation  of  tincturcz  benzoiji  comp.,  3ss-j,  in  aquce 
buL,  Oj,  reheves  the  naso-pharyngeal  and  bronchial  catarrh. 
If  the  bro7ichial  symptoms  become  troublesome,  use — 

R.     Ammonii  muriat., grs.  x 

Spts.  frumenti, f  o  ss 

Mist,  glycyrrh.  comp., ^iss.  M. 

p.  r.  n. 

Should  Pneumonia  occur,  treat  as  an  ordinary  case,  but  never  de- 
press. 

During  convalescence  administer  strychnines  sulph.,  gr.  -^  four 
times  daily. 

TYPHOID   FEVER. 

Synonyms.  Enteric  fever;  gastric  fever;  nervous  fever;  entero- 
mesenteric  fever ;  abdominal  typhus  ;  autumnal  fever. 

Definition.  An  acute,  self-limited,  febrile  affection,  due  to  a 
special  poison  ;  characterized  by  insidious  prodromes  ;  epistaxis  ;  dull 
headache  followed  by  stupor  and  delirium  ;  red  tongue,  becoming 
dry,  brown  and  cracked  ;  abdominal  tenderness,  early  diarrhoea  and 
tympany;  a  peculiar  eruption  upon  the  abdomen;  rapid  prostration 
and  slow  convalescence ;  a  conslant  lesion  of  Peyer's  patches,  the 
mesenteric  glands  and  of  the  spleen. 

Causes.     Predisposing  and  exciting. 

The  chief  predisposing  causes  are  Age,  to  wit,  young  adults, 
between  eighteen  and  twenty-five  years ;  rare  after  forty  years.  I 
have  seen  well-marked  cases  with  typical  symptoms  at  eighteen 
months  and  at  five  years  of  age ;  and  Season,  to  wit,  a  dry  and  hot 
autumn. 

The  exciting  cause  is  a  special  typhoid  germ,  the  bacillus  typhosus. 

The  poison  usually  results  from  the  decomposition  of  the  typhoid 
stools  and  the  sputum,  although  it  has  been  claimed  that  the  disorder 
may  be  generated  under  certain  undetermined  circumstances,  de  ?iovo, 
from  ordinary  filth  and  decomposition. 

The  atmosphere  is  never  impregnated  with  the  fever  germ.  The 
poison  gains  its  entrance  into  the  system  by  means  of  infected  water, 


20    -  PRACTICE   OF   MEDICINE. 

milk,  ice,  meat  or  other  food.  The  germ  is  easily  destroyed  by  thor- 
ough disinfection  of  the  stools  and  sputum  with  heat,  mercuric  bichlo- 
ride or  acidum  carbolicum,  but  it  is  to  be  borne  in  mind  that  extreme 
cold  will  not  destroy  the  typhoid  germ. 

Pathological  Anatomy.  The  specific  anatomical  lesions  of 
typhoid  fever  are  invariably  present,  and  are  so  characteristic  that 
an  examination  of  the  body  after  death  will  in  any  case  make  known 
the  nature  of  the  disease,  even  had  the  symptoms  been  unknown. 
These  lesions  consists  in  changes  in  the  Peye?'ia7i  patches  dind  solitary 
glands,  which  may  be  divided  into  well-defined  stages,  as  follows  : — 

First  Stage.  Swelling,  from  infiltration  and  excessive  proliferation 
of  their  cellular  elements  ;  the  surrounding  mucous  membrane  is 
also  infiltrated  with  cells.  The  Peyer's  patches  are  thickened,  hard- 
ened and  elevated  above  the  mucous  membrane.  The  number  of 
patches  and  glands  involved  is  from  three  or  four  up  to  nearly  the 
entire  number.  The  above  changes  have  been  noted  as  early  as  the 
second  day. 

Second  Stage.  Softeni?ig,  slotighitig  and  tdceration  of  the  solitary 
and  agminate  glands  constitute  this  stage.  Either  of  the  processes 
going  on  in  different  glands  at  the  same  time.  Not  all  the  patches 
necessarily  slough  ;  in  a  certain  number  of  them  the  morbid  changes 
are  arrested  before  softening.  This  stage  constitutes  the  anatomical 
changes  of  the  second  and  third  week. 

Fourth  Stage.  Cicatrization,  or  in  rare  cases,  perforation.  The 
ulcer  gradually  diminishes  in  size,  the  surface  becoming  covered  with 
a  delicate  layer  of  granulations,  which  is  soon  transformed  into  con- 
nective tissue  and  covered  with  epithelium,  the  resulting  scar  being 
slightly  depressed.     The  gland  structure  is  never  regenerated. 

The  Mesenteric  gla?tds  become  infiltrated,  enlarged  and  softened, 
but  seldom  ulcerate. 

The  Spleen  also  enlarges  and  softens.  There  is  besides,  parenchy- 
matous degeneration  or  granular  changes  in  all  the  tissues  of  the  body. 

Syraptoms.  Stage  of  Prodromes. — The  onset  is  insidious,  with 
a  feeling  o{  general  malaise,  vertigo,  headache,  disordered  digestion, 
disturbed  sleep,  epistaxis,  depression,  and  muscular  weakness,  fol- 
lowed by  a  chill  ox  chilliness,  the  patient  being  unable  to  designate 
the  day  when  the  symptoms  began.  In  rare  instances  the  disease 
begins  abruptly  with  a  chill,  followed  by  high  fever;  this  is  particu- 
larly the  case  in  malarial  districts. 


FEVERS.  21 

First  Week,  dates  from  onset  of  the  fever,  when  are  present  increas- 
ing temperature,  freque7it  pulse,  coated  tongue,  7iausea,  diarrhoea, 
headache,  and  upon  the  seventh  day  a  few  reddish  spots  reseniblijig 
fiea  bites  appear  upon  the  abdomen,  chest  or  back. 

Secottd  Weeky  the  foregoing  symptoms  are  exaggerated  ;  fever  con- 
tinuous, frequent  and  coinpressible  pulse,  tympanitic,  tender  abdome7i, 
gurgling  in  the  right  iliac  fosses,  7iocturnal  delirium,  severe  and  con- 
stant headache,  often  stupor,  a  short  cough,  with  distinct  bronchial  rales 
on  auscultation,  irregular  muscular  contractions  {subsultus  te7idinu77i), 
sordes  upon  the  teeth  and  lips,  the  diarrhoea  continuing.  During 
this  stage  deafness  develops,  often  increasing  until  complete,  continu- 
ing into  convalescence.  Disturbances  of  visio7i  are  frequent  in  pro- 
nounced cases. 

Third  Week.  Fever  changes  from  continuous  to  remittent ;  the 
evening  excerbations  continue  as  high  as  the  preceding  week,  and  all 
the  symptoms  remain  about  the  same  until  near  the  end  of  the  week, 
when  a  marked  amelioration  begins. 

Fourth  Week.  The  fever  decidedly  remits ;  almost  normal  in 
morning,  the  pulse  becoming  less  frequent  and  more  full,  the  tongue 
gradually  becoming  clean,  the  abdomen  lessens  in  size,  the  diarrhoea 
ceases,  the  patient  passing  into  a  slow  convalescence,  greatly  ema- 
ciated, which  condition  may  continue  for  several  weeks. 

Analysis  of  Symptoms.  The  te77iperature  record  of  typhoid 
fever  is  a  characteristic  07ie.  The  fever  on  the  morning  of  the  first 
day  may  be  stated  at  98.5°  F.,  evening  100.5°  J  second  morning  99.5°, 
evening  101,5°;  third  morning  106.5°,  evening  102.5°  I  fourth  morning 
101.5°,  evening  1035°;  fifth  evening  104.5°.  From  that  time  until 
end  of  the  second  week,  the  evening  temperature  ranges  between 
103°  and  105°,  the  morning  temperature  being  a  degree  or  more 
lower. 

Diarrhoea  is  the  principal  intestinal  symptom ;  if  absent,  the  lesion 
is  slight.  The  stools  are  at  first  dark,  but  early  in  the  second  week 
they  become  fluid,  offensive,  ochre-yellow  in  color,  resembling  "  pea 
soup,"  and  may  be  .streaked  with  blood.  They  number  from  tJiree  to 
Hfteen  in  the  twenty-four  hours. 

Constipation  occurs  more  frequently  than  is  supposed.  I  have  seen 
fifty  cases  with  constipation  within  the  past  five  years. 

Eruption  is  almost  constant.  Consists  oi  ixovsx  five  to  twenty  small, 
rose-colored  spots  on  the  abdo?7ten,  chest  or  back,  sometimes  on  the 


22  PRACTICE   OF   MEDICINE. 

limbs,  appearing  in  crops,  lasting  about  five  days,  disappeanyig  on 
pressure  and  at  death.  Returning  with  relapses.  Eruption  day 
from  the  seventh  to  the  ninth. 

Rarely  spots  of  a  delicate  blue  tint — the  "  taches  bleuatres  "  of 
French  authors — are  observed. 

Xen'oiis  syniptoins  are,  pronounced  headache,  early  and  severe, 
dullness  of  intellect  soon  following,  passing  into  drowsi?iess  and  stupor, 
with  great  prostration.  Deafness  pronounced.  Sight  impaired,  in 
grave  cases  double  vision.  Delirium  low  and  muttering,  generally 
pleasant  in  character  ;  always  present  in  marked  cases.  Cotna  vigil 
is  a  grave  symptom,  the  patient  lying  perfectly  quiet  with  eyes  open, 
taking  no  heed  to  his  surroundings. 

Muscular  symptoms  are  developed  late  in  the  second  or  early  in 
the  third  week,  and  consist  of  irregular  contractions  or  subsultus  tefi- 
dinum,  and  are  the  result  of  great  debility.  The  reverse  of  muscular 
contractions,  to  wit,  perfectly  motionless  in  bed,  attempting  no  mus- 
cular effort  of  any  kind,  is  a  grave  sign. 

Convalescence  shows  great  debility,  great  anaemia  and  great  nerv- 
ousness, often  very  protracted.  It  is  during  convalescence  that  great 
irritability  of  the  heart,  profuse  night  sweats  and  insomnia  occur,  and 
in  woman  loss  of  the  hair. 

Complications.  Intestinal  hemorrhage  is  the  most  frequent 
and  at  times  the  most  critical  of  any  of  the  complications  of  typhoid 
fever.  The  hemorrhage  may  occur  any  time  between  the  fourteenth 
and  twentieth  day  ;  a  sudden  decline  of  the  temperature  to  the  norm 
or  below  frequently  precedes  the  passage  of  blood  by  stool.  The 
hemorrhage  is  due  to  the  erosion  of  a  vessel  during  the  ulcerative 
action. 

Perforation  makes  the  case  almost  hopeless.  Peritonitis  without 
perforation  adds  to  the  gravity,  but  not  necessarily  fatal.  Lobar pneu- 
monia,  hypostatic  congestion  and  bronchitis  are  frequent  occurrences. 
Albuminuria  may  occur,  as  may  phlegmasia  dolens. 

Relapses  are  common.  The  symptoms  all  return  abruptly ;  the 
duration  is  half  the  time  of  the  original  attack  ;  occur  at  the  end  of 
the  fourth  or  beginning  of  the  fifth  week.  Not  so  fatal  as  generally 
supposed. 

Abortive  typhoid  fever  are  cases  of  mild  character,  having  many 
ot  the  typical  symptoms,  running  its  course  in  about  two  weeks. 
The  so-called  walking  cases  are  often  ot  this  character. 


FEVERS.  23 

Diagnosis.  An  error  that  is  constantly  being  made  is  that  of 
confounding  typhoid  fever  with  the  typhoid  (depressing)  symptoms  or 
condition  developing  during  the  course  of  many  acute  diseases.  The 
absence  of  the  characteristic  diarrhcea,  the  peculiar  eruption,  and  the 
typical  teinperahire  record,  should  prevent  the  error. 

Enteritis  has  intestinal  disorders  alone. 

Peritonitis,  abdominal  symptoms  only,  with  constipation. 

Acute  miliary  tuberculosis  often  mistaken  for  typhoid  fever,  an 
error  difficult  to  prevent  at  times. 

Meningitis  lacks  the  intestinal  symptoms  and  fever  record. 

The  so-called  typho-malarial  or  malaria-typhoid  fever  has  many 
symptoms  in  common,  but  lacks  the  diarrhcea,  eruption,  and  tempera- 
ture record. 

Prognosis.  A  positive  prognosis  cannot  be  made.  Favorable 
indications  are  constipation,  slight  diarrhoea,  low  temperature,  and 
moderate  delirium.  Unfavorable  symptoms  are  obstinate  and  severe 
diarrhoea,  early  high  temperature,  marked  nervous  symptoms  with 
coma  vigil  or  stupor,  albuminuria,  and  repeated  intestinal  hemor- 
rhages. 

The  prognosis  is  always  more  favorable  in  winter  than  in  summer. 

The  mortality  in  typhoid  fever  in  private  practice  is  about  one 
death  in  twenty  ;  in  hospital  practice  it  varies  from  one  death  in  five 
to  ten  cases. 

Treatment.  No  specific.  Chiefly  symptomatic  and  expectant, 
with  intelligent  nursing,  pure  air,  quiet  sick  chamber,  and  disinfecting 
the  uritie  and  the  stools,  with  a  nutritious  liquid  diet  at  intervals  of 
every  two  or  three  hours.  A  word  of  caution,  however,  as  to  the 
quantity  of  food  administered.  The  amount  should  be  small,  as 
the  digestive  capacity  of  the  patient  is  greatly  lessened  by  the  febrile 
phenomena.  Much  harm  results  in  typhoid  fever  from  stuffing  the 
patient. 

The  following  remedies  have  advocates,  claiming  that  they  modify 
the  course  of  the  disease  ;  to  wit :  Hydrargyrum,  iodum,  aciduni  car- 
bolicum,  mineral  acids,  argentmn  nitras,  and  ergota. 

A  mild  case  of  the  disease  will  do  well  with  acidiim  hydrochloricum 
dilutum,  TTLx-xx,  well  diluted,  every  four  hours,  alternated  with 
quinincE  sulphas,  gr.  ij. 

Cases  with  high  temperature  and  costive  bowels  are  sometimes 
wonderfully  benefited  by  the  following : — 


24"  PRACTICE  OF   MEDICINE. 

R .     Hydrarg}Ti  chlor.  mite, ST'  /4 

Pulv.  ipecacuanha, §T'  /^ 

Pulv.  opii, §r.  )^. 

Repeated  every  three  or  four  hours,  and  qicinincB  sulphas,  gr.  ij,  every  four 
hours. 

The  present  so-called  "specific  treatment"  of  this  disease  consists 
in  the  administration  every  second  evening,  until  four  doses  are 
taken,  of  hydrargyri  chlor.  mite,  gr.  vij-x,  which  seemingly  lessens 
the  frequency  of  the  stools  in  the  later  stages  of  the  attack,  although 
slightly  increasing  them  at  the  time.  Also  administering  from  the 
beginning  of  the  attack — 

R.     Tine,  iodi., ^ij 

Acid,  carbol.  liq., 3J.  M. 

SiG. — One,  two,  or  three  drops  in  ice  water,  every  two  or  three  hours,  after  food. 

To  reduce  the  temperature,  use  either  the  cold  bath,  cold  pack,  and 
cold  sponging,  with  qui7tincE  sulph.,  gr.  xv-xx,  repeated  within  an 
hour,  or  antipyrine ,  gr.  xx,  repeated  j^r^  re  nata. 

Diarrhoea  should  not  be  checked  unless  it  exceeds  three  stools  in 
twenty-four  hours,  when  may  be  used — 

R.     Bismuth  subnit., gr.  xx 

Acid,  carbol., gtt.  j 

Tinct.  opii  deodorat., gtt.  x-xv 

Mucil.  acacise, 55  j 

Aquae, ^iij.  M. 

SiG. — Every  three  or  four  hours. 
Or— 

R  .     Cupri  sulph., gr.  ^ 

Extracti  opii, g^"-  X'  ^* 

SiG. — In  pill,  every  four  hours. 

For  Tympajiites ;  cold  compresses  or  turpentine  stupes  to  the  abdo- 
men, or  R.  ol.  terebi7ithi7icE ,  gtt.  x,  morphines  sulph.,  gr.  -^j^,  in  emul- 
sion, every  third  hour,  or  tinct.  tiucis  vomicis,  gtt.  y.,p.  r.  ?i. 

Tympany  with  constipation  is  relieved  by  the  use  of  olei  terebinthince , 
gtt.  X,  olei  ricini,  gtt.  xv,  in  emulsion  every  three  or  four  hours. 

For  Thirst ;  cooling  drinks,  in  moderation,  or  pellets  of  ice  slowly 
dissolved  in  the  mouth. 

Headache ;  cold  to  the  head,  mustard  to  the  neck,  and  foot-baths ; 
if  these  fail  to  relieve,  morphina  or  atropina  hypodermically. 

Delirium  ;  if  from  debility,  increase  the  stimulants ;  other  causes, 
use  morphina. 


FEVERS.  25 

Restlessness  and  coma  vigil ;  chloral  alone  or  with  pofassii  bro- 
fnidujn,  or  morphina. 

Debility ;  food  every  two  or  three  hours;  do  not  permit  sleep  to 
interfere  with  nourishment.  Stiimilants  are  indicated  early  ;  the  best 
guide  being  the  heart's  action  ;  an  average  amount  would  be  ^vj  spts. 
villi gallici,  per  diem,  or  chloroformi  Ttiij-v  every  hour  or  two,  well 
diluted,  or  moschus,  gr.  x,  repeated  p.  r.  n. 

The  bladder  should  be  examined  at  each  visit. 

Ifitestinal  hemorrhage ;  at  once  morphina,  gr.  ^,  hypodermically, 
and  ext.  ergotcB  fl.,  f^j,  repeated  p.  r.  n.,  or  MonseV s  sohition,  gtt. 
ij-iv,  every  two  hours,  or  acidum  tannicum,  gr.  ij-v,  with.  pidv.  opii  ei 
ipecaciiatihcz,  gr.  iij  every  hour. 

Perforation  and  peritotiitis ;  at  once  morphijia  sulphas,  gr.  yi, 
hypodermically  followed  with  extractiim  opii,  gr.  j  every  hour,  hot 
application  to  the  abdomen  and  bold  stimulation. 

TYPHUS  FEVER. 

Synonyms.     Contagious  fever  ;  ship  fever  ;  jail  fever. 

Definition.  An  acute  febrile,  epidemic  disease  ;  highly  contagious, 
and  characterized  by  sudden  invasion,  profound  depression  of  the  vital 
powers,  sickening  odor,  and  a  peculiar  petechial  eruption  ;  favorable 
cases  terminating  by  crisis  about  the  fourteenth  day.     No  lesion. 

Cause,  A  special  infecting  germ,  the  character  of  which  is  un- 
known, but  which  is  influenced  by  filth  and  overcrowding.  Rarely 
seen  in  the  United  States. 

Pathology.  No  constant  lesion.  Blood  dark  and  thin,  with  les- 
sened fibrin  ;  tissues  dark,  soft  and  flabby. 

Symptoms.  Begins  abruptly  ;  chill  followed  by  violent  feve7  ; 
temperature  within  a  few  days  reaching  104°  to  105°  F.  ;  a  frequent, 
bounding  pulse,  soon  becoming  compressible  ;  severe  headache,  fol- 
lowed by  violent  delirium  ;  from  \.h.e  fifth  to  the  seventh  day,  a  coarse, 
red,  measly  eruption,  with  a  mottling  of  the  skin  all  over  the  body, 
except  the  face,  not  disappearing  on  pressure  ;  constipation  the  rule. 
End  of  the  second  week,  the  temperature  suddenly  declines  and  the 
case  passes  into  a  rapid  convalescence. 

Complications.  Pneumonia  and  swollen  parotid  glands  are 
common. 

Diagnosis.  From  typhoid  jever,\\\^  age,  season,  onset  of  the 
disease,  character  of  the  eruption,  and  the  intestinal  symptoms. 


26.  PRACTICE   OF   MEDICINE. 

Measles  begin  milder,  with  coryza  and  cough,  and  seldom  have 
such  pronounced  nervous  phenomena,  but  there  occurs  an  early- 
eruption  appearing  on  the  face. 

Prog"nosis.  Unfavorable  indications  ;  high  temperature,  frequent 
pulse,  early  stupor,  presentiment  of  death.  Favorable  ;  youth,  mod- 
erate temperature  and  pulse,  and  mild  nervous  phenomena. 

Treatment.  Symptomatic.  As  typhus  fever  is  distinctly  conta- 
gious, isolation  is  imperative,  with  immediate  x^T^Q\2X2,wdi  disinfection 
of  the  patient's  excreta. 

All  cases  are  benefited  by  small  doses  of  the  mineral  acids  alter- 
nating with  quinines  sulphas. 

For  high  temperature,  cold  pack,  cold  bath,  cold  sponging,  full 
doses  of  guifiina  or  a7itipyri7ie . 

For  the  headache  and  delirium,  cold  to  the  head,  in  the  young  and 
strong,  a  few  leeches  to  the  temple,  and  chloral^  with  or  without  the 
bromides. 

For  constipation,  mild  laxatives. 

Debility;  alcohol  early  and  in  full  doses,  spi7-itus  chloroformi  in 
drachm  doses,  whenever  danger  of  collapse. 

CEREBRO-SPINAL  FEVER. 

Synonyms.  Epidemic  cerebro-spinal  meningitis;  epidemic  cere- 
bro-spinal  fever;  spotted  fever  ;  cerebro-spinal  typhus. 

Definition.  A  malignant  epidonic  fever,  characterized  by  head- 
ache, vomiting,  painful  contractions  of  the  muscles  of  the  back  of 
the  neck,  retraction  of  the  head,  hypersesthesia,  disorders  of  the 
special  senses,  delirium,  stupor,  coma,  and  frequently  an  eruption 
of  petechia  or  purpuric  spots — a  subcutaneous  extravasation  of  blood. 
Lesions  of  cerebral  and  spinal  membranes  are  found  at  the  post- 
morietn. 

Cause.  A  special  microorganism,  of  oval  shape,  occurring  mostly 
in  pairs  and  faintly  tremulous,  resembling  those  found  in  pneumonia 
and  erysipelas,  though  hardly  identical.  Bad  hygiene  seems  to  favor 
the  development  of  this  affection,  but  can  hardly  be  considered  its 
cause. 

The  disease  seems  to  have  a  predilection  for  the  young.  Occurs 
most  frequently  in  the  winter  months.      Not  contagious. 

Pathological  Anatomy.     The  extent  of  lesion  present  in    a 


FEVERS.  27 

given  case  depends  upon  the  duration  of  the  illness.  In  cases  rapidly 
fatal,  it  is  probable  that  the  subject  is  overwhelmed  by  the  poison  ere 
the  characteristic  anatomical  changes  have  time  to  develop. 

The  changes  in  this  disease  are  twofold,  to  wit :  those  due  to  the 
direct  action  of  the  infecting  poison  upon  the  blood,  producing  the 
group  of  symptoms  constituting  the  fever ;  and  those  giving  rise  to 
the  local  inflammation,  viz.  :  HypercBmia  of  the  membranes  of  the 
brain  and  spinal  cord  followed  by  an  exiidatioti  of  lymph  and  an 
effusion  of  serum,  resulting  in  pressure  on  the  brain  and  cord.  The 
inflammatory  changes  are  more  marked  in  the  membranes  at  the 
base  of  the  brain  than  elsewhere. 

Symptoms.  Divided,  according  to  the  severity  of  the  lesion, 
into  three  groups,  to  wit :  the  common  form,  the  fuhnmant,  and  the 
abortive. 

The  Co?nmon  Form  begins  abruptly  with  a  chill,  excruciating  head- 
ache, persistent  nausea,  vo7niti?ig,  vertigo,  and  an  overwhelming  sense 
of  weakness.  Within  a  few  hours  the  muscles  of  the  back  of  the  neck 
become  rigid  and  retracted,  with  decided  paiji  upon  moving  the 
head;  this  rigidity  and  retraction  soon  extends  to  the  back,  when 
opisthotonos  occurs.  There  is  great  restlessness,  and  the  surface  of 
the  body  becomes  highly  sensitive  {hypercssthesia).  Cramps  in  the 
muscles  of  the  legs  and  elsewhere,  and  spasmodic  twitchings  of  the 
lips  and  eyelids  come  and  go,  and  finally  convulsiojis  or  delirium 
occur.  Intolerance  of  light,  and  in  some  cases  amaurosis,  more  or 
less  deafness,  loss  of  sense  of  smell  and  taste  soon  following.  The 
temperature  and  pulse  records  are  irregular.  From  \}!\^  first  day  to 
\.h.Q  fifth  an  eruption  of  petechias  or  purpura  occurs  in  the  majority  of 
cases.  The  disease  reaches  its  height  in  from  three  to  eight  days, 
and  passes  into  stupor  d^nd  co)na,  or  ameliorates  imd  passes  into  a 
protracted  convalescence. 

The  Fulminant  Form.  Severe  chill,  depression,  and  in  a  few  hours 
collapse.     The  patient  is  overcome  by  the  poison  and  never  reacts. 

The  Abortive  Form'zox\.svsXs  of  one  or  more  pronounced  character- 
istic symptoms  during  the  course  of  an  epidemic. 

Sequelae.  Result  from  thickening  of  either  the  cerebral  or  spinal 
membranes ;  persistent  headache,  blindness  or  deafiess,  partial  or 
complete ;  epilepsy,  or  different  forms  of  sfinal palsies. 

Complications.  Pneumonia;  typhoid  fever;  pleuritis ;  intesti- 
nal catarrh,  in  infants. 


28  ,  PRACTICE   OF   MEDICINE. 

Diagnosis.  TypJwid  fever  begins  slowly,  has  a  characteristic 
temperature  record,  ivitJioict  so  mtense  headache,  muscular  rigidity, 
vomiting,  early  delirium,  ending  in  coma. 

Typhus  fever  has  higher  fever,  is  of  longer  duration,  and  has  a 
peculiar  measly  eruption,  is  not  attended  with  muscular  rigidity  and 
retraction,  hyperaesthesia,  nor  disorders  of  the  special  senses. 

Titbercular  vieni7igitis  is  not  epidemic,  has  no  characteristic  erup- 
tion ;  is  preceded  by  long  prodromes,  and  runs  a  tedious  course. 

A  congestive  r///// resembles  i\\&fuhni7ia7it  c2iSQ:s,  in  suddenness  of 
depression,  but  the  latter  has  not  the  history  of  the  former. 

Inflammation  of  tJie  nieninges  of  the  cord  is  due  to  exposure  to 
cold,  or  syphilis,  and  is  not  attended  with  cerebral  symptoms  or  an 
eruption. 

Prognosis.  Varies  according  to  epidemic  ;  from  twenty  to  fifty, 
and  even  seventy-five  per  cent.  die. 

Treatnient.  There  is  no  abortive  plan  of  treatment  for  cerebro- 
spinal fever,  nor  can  the  antiphlogistic  treatment  of  the  inflammatory 
symptoms  be  advised.  Like  the  infectious  diseases  in  general,  sus- 
taining measures  are  indicated  in  all  but  the  most  sthenic  cases. 

Nutritious  and  easily  assimilated  food,  such  as  milk,  eggs,  meat- 
juice  and  broths,  should  be  given  at  regular  intervals  night  and  day. 
If  food  cannot  be  taken  by  the  mouth,  nutritious  enemata  should  be 
substituted. 

The  drug  that  holds  the  highest  place  in  the  treatment  of  this  dis- 
ease is  opium. 

The  hypodermic  use  of  morphijia,  gr.  ^  to  ^  every  two  or  three 
hours ;  or  extractum  opii,  gr.  j  every  hour  until  stage  of  effusion  in 
adults,  when  quinina  in  tonic  doses  and  poiassii  iodidum  are  indicated. 
Prof.  DaCosta  zSx^xvidXts  potassii  bromidutn  with  opium,  especially  in 
children. 

Locally,  warmth  to  the  surface,  with  hot  sponging  along  the  spinal 
column  and  to  the  nape  of  the  neck.  The  cautious  use  of  cold  com- 
presses to  the  head  for  headache  may  be  useful  in  some  cases. 

For  sequela;,  potassii  iodidum,  a  course  of  hydrargyrum,  oleum 
morrhucE,  and  flying  blisters  along  the  spinal  column. 


FEVERS.  29 

RELAPSING  FEVER. 

Synonyms.     Famine  fever  ;  bilious  typhoid  fever. 

Definition.  An  epidemic,  contagious,  febrile  disease,  self  limited  ; 
characterized  by  a  febrile  paroxysm,  succeeded  by  an  entire  inter- 
mission, which  is  in  turn  followed  by  a  r^/«/^^  similar  to  the  first 
seizure.     No  specific  lesion. 

Cause.  A  specific  poison  ;  contagious ;  acquiring  the  greater 
activity  the  more  filthy,  crowded  and  unhealthy  the  population  amid 
which  it  prevails. 

Pathological  Anatomy.  During  the  febrile  paroxysm  only, 
blood  contains  minute  cork-screw-shaped  organisms  or  spiral  fila- 
ments— spirilli,  constantly  twisting  and  rotating. 

Liver  and  spleen  greatly  swollen. 

Symptoms,  '^o prodromes.  Onset  abrupt,  with  fever,  io2°-ic4°; 
frequent,  rather  weak  pulse,  headache,  nausea,  voniitijig,  and  lanci- 
nating/^zVz^  in  limbs  and  muscles,  marked  in  the  calf  of  leg  ;  secojid 
day,  feeling  oi fullness  2Sv^  pre s stir e  in  right  and  left  hypochondrium, 
due  to  swollen  liver  and  spleen  ; /azm^//*:.?  is  frequent;  seventh  day 
fever  ends  by  crisis  ;  fourteenth  day  symptoms  return  in  milder  form, 
continuing  about  four  days,  when  enters  slow  convalescence,  much 
emaciated.     No  eruption.     Several  relapses  may  occur. 

Diagnosis.  Yellow  fever  has  'many  points  of  resemblance,  but 
has  a  shorter  febrile  stage,  remissions  not  so  complete,  vomiting  late 
and  characteristic,  normal  spleen,  and  the  late  appearance  of  yellow 
color. 

Re?nittent  fever  begins  with  a  decided  chill,  followed  by  fever  and 
sweats,  and  not  the  progressive  rise  of  temperature  till  the  fifth  or 
seventh  day. 

Prognosis.  Recovery  the  rule,  but  protracted,  and  decided 
emaciatioti  results. 

Treatment.  Expectant.  Act  on  secretions;  nourish  patient  and 
meet  urgent  symptoms.  For  fever,  antipyretic  doses  of  quinina  which, 
however,  has  no  power  to  prevent  the  relapses;  for  pain,  hypoder- 
mic injections  of  vioiphiiia  ;  for  nausea  and  vomiting,  acidum  carbo/i- 
cum  or  cerii  oxalas  ;  during  re  mission, /t'rr/^;;/  and  guitwta  in  tonic 
doses. 


30  PRACTICE   OF   MEDICINE. 

PERIODICAL  FEVERS. 

These  affections  are  characterized  by  the  distinct  periodicity  of  the 
phenomena,  having  intervals  during  which  the  patient  is  wholly  or 
TiQ2Lx\y  free  from  fever. 

INTERMITTENT  FEVER. 

Synoriyms.  Ague  ;  chills  and  fever ;  malarial  fever ;  swamp 
fever. 

Definition.     A  paroxysmal  fever,  the  phenomena   observing   a 
regular  succession  ;  characterized  by  a  cold,  a  hot  and  a  sweating 
stage,  followed  by  an  interval  of  complete  intermission  or  apyrexia, 
varying  in  length,  according  to  the  variety  of  the  attack. 
Cause.     Malaria.     Bacillus  Malaria  ? 

The  period  of  incubation  varies  from  a  few  days  to  weeks,  months 
or  even  years,  an  auxiliary  condition  such  as  exposure  to  cold,  over- 
exertion, excesses  in  eating  and  drinking,  or  great  excitement  often 
being  necessary  to  give  efficiency  to  the  special  cause. 

Either  sex  and  all  ages  are  susceptible  to  the  poison. 

Pathological  Anatomy.  Blood  dark,  from  the  formation  of 
pigment  {Melancsmia).  Spleen  swollen  {Ague  cake).  Liver  engorged 
and  swollen. 

Varieties.  Quotidian  when  a  daily  paroxysm  ;  tertian  when  every 
other  day  ;  quartan  when  it  occurs  first  and  fourth  days  ;  octa7i  when 
weekly;  duplicated  quotidian  when  two  paroxysms  daily;  duplicated 
tertiaii,  two  every  second  day  ;  double  tertiaft,  daily  paroxysm,  but 
more  severe  every  second  day.  Dumb  ague,  or  masked  ague,  pre- 
sents irregularity  of  the  characteristic  phenomena. 

Symptoms.  Each  paroxysm  has  three  stages,  the  cold,  hot  and 
sweating. 

Cold  stage  begins  with  prodromes,  to  wit :  lassitude,  yawning,  head- 
ache and  nausea,  followed  by  a  chill ;  the  teeth  chatter,  skin  pale, 
nails  and  lips  blue,  the  surface  rough  and  pale,  the  so-called  goose- 
skin  or  cutis  anseri7ia,  nausea  and  great  thirst,  while  the  thermometer 
in  the  axilla  or  mouth  shows  a  decided  rise  of  temperature,  102°  F.- 
104° ;  these  phenomena  continuing  from  one-half  to  an  hour. 

Hot  stage  begins  gradually,  by  the  shivering  ceasing,  the  surface 
becoming  hot  and  flushed,  the  temperature  rising  to  106°  F.,  or  more, 
pulse  full,  headache,  nausea,  intense  thirst,  dry,  flushed,  swollen  skin, 


FEVERS.  31 

scanty  urine  and  other  phenomena  of  Pyrexia,  continuing  from  one 
to  eight  or  ten  hours. 

Sweating  stage  begins  gradually,  first  appearing  on  the  forehead, 
then  spreading  over  the  entire  surface  ;  \}^^fei>er  lessejis,  the  tempera- 
ture rapidly  falling  to  99°  or  98°,  pulse  less  full,  headache  lessens,  and 
a  general  feeling  of  comfort  exists,  sleep  often  following  ;  duration  of 
the  sweating  from  one  to  four  hours,  when  the  intermission  occurs,  the 
patient  apparently  well,  except  for  a  feeling  of  general  debility. 

The  occurrence  of  the  next  paroxysm  depends  upon  the  variety  of 
the  attack. 

The  paroxysm  may  be  ushered  in  by  a  decided  pain  in  one  or  more 
nerves,  instead  of  the  cold  stage,  to  wit :  "  brow  ague.'' 

Diagnosis.  No  difficulty  when  the  characteristic  chill,  fever,  and 
sweats  occur. 

Hectic  fever.  Distinguished  by  its  irregularity,  and  occurring  sec- 
ondary to  an  organic  disease. 

PycBinia  produced  by  other  causes  than  malaria. 

Nervous  chills  show  an  absence  of  the  temperature  rise. 

Prognosis.  Recovery  the  rule.  Without  treatment  many  cases 
end  favorably  after  several  paroxysms  ;  others  passing  into  the  chronic 
form  or  malarial  cachexice. 

Treatment.  Cold  stage  can  be  averted  and  the  other  stages 
greatly  modified  by  a  hypodermic  injection  of  either  morphines  sulph., 
gr.  y%-%,  ox  pilocarpincE  hydrochloras,  gr.  yi,  or  chloroformi  spts.,  f^j, 
by  the  stomach.  Hot  stage,  cool  drinks  and  cold  sponging.  Sweat- 
ing stage,  when  excessive,  sponging  with  alujnen  and  hot  water. 

Intermission ;  2l\.  once  a  brisk  purgative,  followed  by  cinchofia  in 
some  form,  the  most  efficient  being  guini?icB  sidph.,  gr.  xx-xxiv,  in 
solution  or  freshly-made  pills,  in  one  or  two  doses,  three  \o  five  hours 
before  the  expected  paroxysm.  Many  substitutes  are  lauded  to  replace 
the  salts  of  cinchona  bark,  but  without  avail. 

After  the  paroxysms  are  broken  up,  use  liq.  potassii  arsenit.,  gtt. 
v-x,  /.  d.,  for  a  long  time,  or  tinct.  ferri  chloridi,  gtt.  xx,  every  four 
hours,  or  a  combination  like  the  following  : — 

R.     Ferri  reducti, 

Quininse  sulph., aa gr.  xlviij 

Acidi  arseniosi, gr.  j 

01.  pip.  nigr., gtt.  xv.         M. 

Ft.  pil.  No.  xxiv. 

SiG. — One  pill  after  meals,  continued  for  one  month,  at  least. 


32  PRACTICE   OF   MEDICINE. 

Relapses  being  common,  quifihia  should  be  given  on  the  second  or 
third  6.2LY,  fourth  to  the  sixth,  twelfth  to  the  fourtce7ith,  and  tiine- 
ieenih  to  the  tivefity-frst  days. 


REMITTENT   FEVER. 

Synon37TQS.  Bilious  fever;  bilious  remittent  fever;  marsh  fever; 
typho-malarial  fever  ? 

Definition.  A  paroxysmal  fever,  with  exacerbations  and  reinis- 
siois  ;  characterized  by  a  moderate  cold  stage  (which  does  not  recur 
with  each  paroxysm)  ;  an  intense  hot  stage,  with  violent  headache 
and  gastric  irritability  ;  and  an  almost  imperceptible  sweating  stage, 
which  is  frequently  wanting. 

Cause.     Malaria,  aided  by  high  temperature. 

Pathological  Anatomy.  Blood  dark  {^Melancemid) ;  spleen 
enlarged,  soft,  filled  with  blood,  and  of  an  olive  color  ;  liver  con- 
gested and  swollen,  and  of  a  bronze  hue;  the  brain  hypersemic  and 
olive-colored  ;  gastro-intestinal  canal  markedly  hyperaemic. 

Symptoms.  Cold  stage ;  moderate  chill,  the  temperature  rising 
1°  to  2^,  coated,  dry  tongue,  oppressio7i  at  the  epigastrium,  slight 
headache,  and  pains  throughout  the  body. 

Hot  stage ;  persistent  vomiting,  furred  ionguQ,  full  pulse,  rising  to 
loo  or  I20,  flushed  face,  i7ijected  eye,  violent  Jieadache,  pains  in  limbs 
and  loins,  hurried  respiratio7t,  the  te77iperature  rising  to  104°  F.,  or 
106°.  The  bowels  costive,  stools  tarry  and  offensive,  and  the  surface 
becoming  yellow.  Deliriu77i  occurs  when  the  temperature  is  very 
high. 

Sweating  stage  ;  after  six  to  twenty-four  hours,  the  above  symptoms 
abate,  and  slight  sweati7tg  occnrs  ;  Xho.  pulse,  headache  and  vo77iiting 
subside,  and  the  te7nperature  falls  to  100°  F.,  or  99°. 

This  is  the  re77iission. 

After  some  two  to  eight  or  twelve  hours,  the  symptoms  of  the  hot 
stage  return,  generally  7ninus  the  chill,  and  this  is  termed  the  exacer- 
bation, which  is  in  turn  again  followed  by  the  re7)iissio7i. 

Duration.  From  seven  to  fourteen  days,  the  average.  Fre- 
quently the  fever  ceases  to  re77tit,  and  instead,  becomes  continuous, 
the  symptoms  resembling,  if  they  are  not  identical  with,  the  typhoid 
state,  whence  the  term  typho-77ialarial  fever,  or  77ialario-typhoid 
feifer. 


FEVERS.  33 

Sequelae.  The  malarial  cachexia  results  when  the  poison  has 
not  been  eliminated  from  the  system. 

Persistent  headache  and  vertigo  are  the  results  of  the  intense 
meningeal  hyperaemia  that  sometimes  occurs. 

Diagnosis.  In  intermittent  fever  each  paroxysm  begins  with 
a  chill,  while  the  chill  seldom  recurs  in  remittent  fever  ;  a  distinct 
intermission  follows  each  paroxysm  of  the  intermittent  form,  while  a 
remission  occurs  in  remittent,  the  thermometer  showing  that  the  fever 
does  not  wholly  disappear;  during  the  intermission  the  patient  is 
apparently  well ;  such  is  not  the  case  in  the  remission  of  remittent 
fever. 

Typhoid  fever  is  mistaken  for  remittent  fever,  but  the  absence  of 
the  characteristic  temperature  record,  diarrhcea,  eruption,  tympanites, 
deafness,  and  severe  prostration,  should  prevent  such  an  error. 

ProgTiosis.     Uncomplicated  cases  are  favorable. 

Treatment.  QuinincB  sulph.,  gr.  xvj-xx  per  diem,  is  the  remedy. 
Better  administered  during  the  remission,  if  possible.  If  an  irritable 
stomach  prevents  its  administration  by  the  mouth,  use  it  by  the  hypo- 
der7nic  ii^ethod  or  in  a  suppository.  During  the  hot  stage,  cool  spong- 
ing, cold  to  the  head,  and  if  a  tendency  to  cerebral  congestion,  dry  or 
wet  cups  to  the  nape  of  the  neck  and — 

Ijt.     Tinct.  acoait.  tad., gtt- Hj 

Liq.  potas.  citrat., ^ij 

Liq.  ammon.  acetat., ^ij.  M. 

Every  two  hours. 

Purgatio7i  during  the  remission,  with — 

R .     Hydrarg.  clilor.  miti? gr-  v 

Sodii  bicarb,, gr.  x 

Pulv.  aromat., gr.  v,  M, 

In  pulv.  p.  r.  n. 

The  same  precautions  are  essential  after  the  paroxysms  are  broken 
up,  to  prevent  their  return  on  the  septenary  periods,  that  were  recom- 
mended for  intermittent  fever. 


PERNICIOUS   FEVER. 
Synonyms.     Congestive   fever ;    mahgnant    intermittent   fever ; 

malignant  remittent  fever. 

Definition.     A  malignant,  destructive  malarial  fever,  which  may 


34  PRACTICE   OF   MEDICINE. 

be  of  the  intermittent  or  remittent  form  ;  characterized  by  intense 
congestion  of  one  or  more  internal  organs,  together  with  dangerous 
perversion  of  the  functions  of  innervation. 

Cause.     A  high  degree  of  malarial  poison. 

Varieties.  G astro-enteric ;  thoracic;  cerebral;  hemorrhagic; 
algid. 

Symptoms.  Any  of  these  varieties  may  begin  either  as  in  inter- 
?nittent  or  remittent  fever;  again,  \}i\&  first  paroxysm  is  rarely  per- 
nicious, but  appears  as  the  ordinary  malarial  attack. 

T\iQ  gastro-ejiteric  variety  has  as  distinctive  features,  intense  nausea 
and  vomiti7ig,  purging  of  thin  discharges  mixed  with  blood,  tenesmus, 
burning  heat  in  stomach,  intense  thirst,  frequent,  weak  pulse,  face, 
hands  and  feet  cold,  with  shrunken  features,  and  intense  depression 
of  all  the  vital  forces.  This  condition  continues  from  half  an  hour  to 
several  hours,  when  either  an  inter-  or  remission  occurs. 

Thoracic  variety  often  combined  with  the  one  just  described.  Its 
characteristic  features  are  due  to  overwhelming  congestion  of  the 
lungs,  such  as  violent  dyspjioea,  gaspi?tg  for  air,  fifty  to  sixty  respira- 
tions per  minute,  oppressed  cough  with  slight  amount  of  blood- streaked 
s-^vA.2i,freque7it,  weak  pulse,  cold  surface,  and  terror-stricken  features. 
Duration  same  as  the  above. 

Cerebral  variety,  due  to  intense  congestion  of  the  brain  ;  sometimes 
effusion  of  serum  into  the  ventricles,  or  even  rupture  of  small  blood- 
vessels. Characterized  by  viole?tt  delirium,  followed  by  stupor  and 
coma,  slow,  full  pulse,  the  surface  ^\\\v&x  flushed  ox  livid.  Cases  may 
either  resemble  apoplexy — comatose  variety,  or  acute  mejiingitis — 
delirious  variety.     Duration  same  as  the  other  forms. 

Hemorrhagic  variety,  or  the  yellow  disease,  as  it  has  been  termed, 
begins  as  an  ordinary  inter-  or  remittent  fever,  soon  followed  by  signs 
o{  internal  congestion,  to  wit :  7iaicsea,  vomiting,  dyspnoea,  severe  pains 
over  liver  and  kidjiey,  continuing  for  a  few  hours,  when  the  surface 
suddenly  X.wxn's, yellow  and  bloody  tcri7ie  is  voided,  after  which  an  inter- 
or  remission  and  marked  abatement  occur,  to  be  sooner  or  later  fol- 
lowed by  a  second  paroxysm,  which  is  more  severe,  with  additional 
signs  o{  cerebral  congestion.  Blood  may  also  escape  from  other  parts 
than  the  kidneys. 

Algid  \z.x\e\.y '\s  characterized  by  intense  cold7iess  of  the  surface, 
while  the  rectal  temperature  ranges  from  104°  to  107°  F.  The  attack 
begins  with  a  chill,  which  is  soon  followed  hy  fever  oi  variable  dura- 


FEVERS.  35 

tion,  when  the  body  becomes  cold,  the  axillary  temperature  falling  to 
90°,  88°  or  even  85°  F.,  a  cold  sweat  covers  the  surface,  the  tongue  is 
white,  moist  and  cold,  the  breath  is  icy,  the  voice  feeble  and  indistinct, 
\.\i& pulse  slow,  feeble  and  often  absent  at  the  wrist,  and  with  all  these 
symptoms,  the  patient  complains  of  a  sensa.tion  of  burning  and  intense 
thirst.     The  mind  is  clear,  but  the  countenance  is  death-like. 

Duration.  Pernicious  fever,  in  any  of  its  forms,  may  continue 
from  a  few  hours  until  one,  two  or  three  days.  Recovery  is  rare  after 
a  second,  almost  never  after  a  third,  paroxysm. 

Diagnosis.  Yellow  fever  is  most  apt  to  be  confounded  with  the 
hemorrhagic  variety,  and  as  they  both  occur  in  the  same  localities, 
the  diagnosis  is  difficult ;  the  early  yellowness  of  the  surface,  with 
hcematuria,  and  the  absence  of  the  black  vomit,  an  epidemic  preva- 
lence, are  the  chief  points  of  distinction. 

The  cerebral  variety  may  be  mistaken  for  cerebral  apoplexy,  men- 
ingitis ?\i.x\di  urcemic  convulsions.  Nor  is  it  always  an  easy  matter  to 
differentiate  between  these  conditions. 

The  gastro-e?tteric  variety  may  be  mistaken  for  the  early  stage  and 
the  algid  variety  for  the  latter  stage  of  cholera,  but  the  epidemic 
prevalence  of  the  latter  should  be  of  material  aid  in  determining  the 
diagnosis. 

Prog'nosis.  In  all  varieties  the  result  is  unfavorable,  unless  it 
can  be  controlled  prior  to  the  second  paroxysm.  Cases  in  which  an 
ititermission  occurs  are  better  controlled  than  where  a  remission 
follows.     The  mortality  is  otie  in  eight  from  all  plans  of  treatment. 

Treatment.  The  first  indication  in  all  varieties  is  to  bring  about 
reactio7i.  If  the  cold  stage,  heat  to  the  surface,  with  stimulating  lo- 
tions ;  if  the  hot  stage,  cold  to  the  surface  and  the  hypodermic  injection 
oi  7norphina,  gr.  ]^ ,  at  once.  After  reaction,  guinincE  sulph.,  not  less 
than  gr.  xl,  repeated  p.  ri  n,  ;  administer  by  stomach,  rectum,  or  better 
still,  by  hypodermic  injection.  Dr.  Bartholow  pronounces  the  follow- 
ing one  of  the  best  formulas  for  the  hypodermic  use  of  quinina  : — 

R-     Quininge  disulph.,  ,    , gr.  1 

Acid,  sulph.  dil., m^c 

Aquae   font., ^j 

Acid,  carbol.  liq., TT\^v.  M. 

The  following  formula,  known  as  "  Warburg's  Tincture,"  has  dur- 
ing the  last  few  years  gained  considerable  reputation  in  the  various 
forms  of  malarial  fevers  : — 


36    "  PRACTICE   OF   MEDICINE. 

R .     Rad.  rhei,    P.    aloe   soc.  and   Rad.  angelica 

officinalis, aa ^iv 

Rad.    helenii,   Crocus    Hispan.,  Sem.    foeni- 

culi,  and  Cretce  preparat.,    .    .    .  aa  .    .    .   ^ij 
Rad.    gentian,     Rad.    zedoar,    P.  cubeb,   G. 
myrrh,    G.   camphor,    and     Boletus    Lari- 

cis, aa .^j 

Confect.  damocratis,* ,^  iv 

Quinince  sulph., ^Ixxxij 

Spt.  vini  rect., Oxx 

Aquae  purae, Oxij 

Macerate  in  a  water  bath  twelve  hours,  express  and  filter. 

Each  half  ounce  contains  quininae  sulph.,  gr.  vijss.  If  the  stomach 
is  too  irritable  to  retain  the  tincture,  the  tincture  may  be  evaporated 
to  dryness  and  admini.stered  in  capsules,  each  containing  the  equiva- 
lent of  either  one  or  two  drachms. 

For  the  gastro-ejiteric  variety.  Prof.  Da  Costa  suggests — 

R  .     Morph.  sulph., gr.  | 

Pulv.  camph., gr.  j 

Mass.  hydrarg., g^-  ij 

Pulv.  capsici., gr.  ss.  M. 

In  pills  every  half-hour  until  the  character  of  the  stools  change. 

For  the  thoracic  variety,  dry  or  wet  cups  and  ammo7iii  carbonas. 
For  the  cerebral  variety,  venesection,  or   cups   or  leeches   to  the 

neck,  cold  to  the  head,  prompt  purgation,  and  acting  on  the  kidneys 

and  skin. 

*  Formula  of  Confectio  damocratis  : — 

Cinnamon xiv  Gm. 

Myrrh xj  Gm. 

White  agaric,  Spikenard,  Ginger,  Spanish  saffron 

Treacle,    Mustard    seed,    Frankincense,     and 

Chian  turpentine aa x  Gm. 

Camel's  hay,  Costus   arabacus,  Zeodary,  Indian 

leaf,   Mace,    French    lavender,    Long   pepper, 

Seeds  of  harwort,  Juice  of  rape  cistus,  Strained 

storax,  Opponex,  Strained  galbanum,  Balsam  of 

Gilead,  Oil  of  nutmeg,  Russian  castor.  .  aa  .    .   viij  Gm. 
Water    germunder,     Balsam   tree    fruit,   Cubeb, 

White   pepper.  Seeds  of  carrot  of  Crete,  Foley 

mont,  Strained  bdellium aS,  .    .        .    .    vij  Gm. 

Gentian  root,  Celtic  hard,  Leaves  of  Dittany  of 

Crete,  Red  rose,  Seeds  of  Macedonium,  Parsley, 

Sweet  fennel  seed,  Seeds   of  lesser  cardamon, 

Gum  arable.  Opium a.S. v  Gm. 

Sweet  flag,  Wild  valerian,  Anise  seed,  Sagaper- 

num aa  .    , iij  Gm. 

Spigrul.St.  John's  wort.  Juice  of  acacia.  Catechu, 

Dried  bellies  of  skunk    .    .    .    .   aa ijss  Gm. 

Clarified  honey cmxv  Gm. 

The  roots  to  be  finely  powdered  and  the  whole  mixed  thoroughly. 


FEVERS.  37 

For  the  algid  variety  warjnth  to  the  surface,  hypodermic  use  of 
morphina  and  the  free  use  of  ammonii  carbonas  and  alcoholic  stimu- 
lants. 

For  the  hemorrhagic  variety,  purgatives,  morphina  hypodermic- 
ally,  and  either  acid  sulph.  dil.,  acid,  gallic,  MonseF s  solution,  or 
terebijithina,  for  the  hemorrhages. 

The  following  is  highly  spoken  of  for  hemorrhages : — 

R  •     Ext.  ergotse  fld., ,^  ss 

Acid,  sulph.  dil.,     ....        f,:^iss 

Acid,  gallic, ^j 

Syr.  zingib., f  .^  iij 

Aqu^,  q.  s., ad  .    .    .    .   f^iij.  M. 

SiG. — Dessertspoonful  every  4  hours,  well  diluted. 

After  the  paroxysms  are  controlled,  a  long  course  oi  ferrtmi,  with 
quinina  on  the  septenary  days. 


YELLOW  FEVER. 

Synonyms.  Bilious  malignant  fever ;  typhus  icterode ;  Medi- 
terranean fever ;  sailors'  fever. 

Definition.  An  acute,  infectious,  paroxysmal  disease  of  three 
stages,  to  wit :  the  febrile,  the  rejnission,  and  the  collapse  ;  character- 
ized by  violent  fever,  yellowness  of  the  surface,  and  "  black  or  coffee- 
ground  vomit."  Tendency  fatal ;  one  attack  confers  immunity  from 
a  second. 

Cause.  A  specific  poison,  existing  only  with  a  high  temperature 
and  destroyed  by  frost.     Not  due  to  the  malarial poiso7i. 

Patholog"ical  Anatomy.  Skin  lemon  or  greenish-yellow  color, 
due  to  dissolution  of  the  red  blood  corpuscles  ;  heart  softened  by 
granular  degeneration  ;  stomach,  veins  deeply  engorged,  the  mucous 
membrane  softened,  and  containing  more  or  less  "  coffee-ground" 
matter,  which  consists  of  blood  corpuscles  deprived  of  their  haemo- 
globin, white  corpuscles,  epithelial  cells  and  debris,  hitestiiies  much 
the  same  as  the  stomach  ;  liver,  yellow  color  and  a  fatty  degeneration 
of  the  hepatic  cells  ;  kidneys,  granular  degeneration  of  the  epithelium 
of  the  tubules. 

Symptoms.  First  stage,  the  febrile,  beginning  either  with  the 
prodromata  of  malaise,  headache  and  anorexia,  or  suddenly  with  a 
chill,  high  fever,  in  a  few  hours  reaching  104°  to  106°  F.,  high  pulse 


38    ■  PRACTICE   OF   MEDICINE, 

90-100  beats, /^rzy/zVz;// <?/<?,  flushed  countenance,  coated  tongue,  irn- 
tabi/iiy  o^  lh.Q  stomach,  and  severe  neuralgic  pains  in  the  head,  Hmbs, 
epigastrium,  back  and  large  joints.  The  patients  are  restless,  anx- 
ious, with  a  feeling  of  general  prostration.  In  severe  attacks  ^<?/m«??? 
is  frequent.  Albumin  in  the  urine,  and  a  peculiar  and  characteristic 
odor  is  emitted  from  the  patient.  Duration  of  the  first  stage  from 
thirty-six  hours  to  three  or  four  days. 

Second  stage,  the  remission,  when  the  temperature  declines  to  100° 
or  101°  F,,  and  all  the  distressing  symptoms  abate  or  subside  and, 
with  some  critical  evacuation,  convalescence  occurs,  or,  more  com- 
monly, after  from  a  few  hours  to  one  to  four  days,  the 

Third  stage,  the  stage  of  collapse,  or  the  period  of  secondary  fever, 
is  ushered  in  by  a  return  of  all  the  symptoms  of  the  first  stage  in  an 
exaggerated  form,  followed  by  yellowness  of  the  skin,  passing  to  a 
deep  mahogany  color,  black  vomit  and  hemorrhages  from  other  parts, 
feeble  pulse,  cold  surface,  irregular  respiration,  and  death  from  ex- 
haustion, the  mind  remaining  clear  until  the  end. 

The  above  symptoms  represent  a  sthenic  case  ;  other  varieties  are 
the  algid,  hemorrhagic  and  typhus. 

Duration.  Depends  upon  the  variety  ;  from  a  few  hours  to  a  few 
days.     Rarely  continues  longer  than  one  week. 

Diagnosis.  Pernicious  fever,  hemorrhagic  variety,  is  apt  to  be 
mistaken  for  yellow  fever.  Yellow  fever  is  a  disease  of  one  paroxysm, 
and  one  remission,  epidemic,  with  albuminuria  and  black  vomit.  Per- 
nicious fever  has  more  than  one  paroxysm,  not  epidemic,  rarely  black 
vomit  or  albumin  in  urine. 

Prognosis.  One  in  four  perish.  Short  cases  unfavorable,  as  are 
the  hemorrhagic  and  algid  varieties. 

Treatment.  No  specific ;  a  "  self-limited  "  disease.  The  indica- 
tions are  to  treat  the  symptoms  and  nourish  the  patient.  Good  nursing, 
ventilation,  early  emesis  and  purgation,  with  diaphoretics  and  diu- 
retics, are  apparently  beneficial.  Large  doses  of  quinina,  early  in 
the  attack,  for  high  temperature ;  for  the  irritable  stomach,  ice  slowly 
dissolved  in  the  mouth  and  acidum  carbolicum,  gr.  %  in  aqua  me7ithcE 
pip.,  every  two  hours,  alternated  with  liquor  calcis  and  milk,  each  an 
ounce,  or — 

R .     Hydrargyri  chlor.  mite, g*"*  A 

Morphina:  sulph., g*"-  21- 

Every  two  hours  until  nausea  controlled. 


FEVERS.  39 

For  the  black  vomit  and  hemorrhages,  either  liquor  ferri  subsul- 
phatis  or  phimbi  acetas.  The  pains,  restlessness  or  delirium  are  best 
controlled  by  the  hypodermic  use  of  morphina  or  atropina.  Free 
stimulation  from  the  onset  is  essential. 


ERUPTIVE  FEVERS. 

As  a  group,  the  eruptive  or  exanthematous  fevers  have  many  fea- 
tures in  common.  All  have  a  period  of  incubation,  are  characterized 
by  a  fever  of  more  or  less  intensity  preceding  the  eruption,  by  an  erup-, 
tion  which  is  peculiar  to  each,  occurring  most  commonly  in  childhood, 
rarely  attacking  the  same  person  twice,  very  prone  to  occasion  serious 
sequelae,  and  are  contagious.     Their  origin  is  as  yet  undetermined. 

SCARLET  FEVER. 

Synonym,     Scarlatina. 

Definition,  An  acute,  self-limited,  infectious  disease  ;  character- 
ized by  high  temperature,  rapid  pulse,  a  diffused  scarlet  eruption, 
terminating  with  desquamation,  inflammation  of  the  throat,  and 
frequently  more  or  less  grave  nervous  phenomena.  Serious  sequelae 
frequently  follow  an  attack.  One  attack  confers  immunity  from  the 
disease. 

Pathological  Anatomy.  An  acute  inflammation  of  the  skin, 
with  exudation — a  true  Dermatitis.  A  granular  change  in  all  the 
glandular  structures,  most  marked  in  the  Peyerian  glands,  although 
also  occurring  in  the  stomach  and  kidneys. 

Cause.  A  specific  poison,  maintaining  its  vitality  for  along  time. 
Highly  contagious,  the  contagion  residing  chiefly  in  the  desqua- 
mated epidermis.  Klebs'  micrococci,  the  "  monas  scarlatinosum," 
may  prove  to  be  the  poison.     Incubation  short,  one  to  seven  days. 

Varieties.  Scarlatina  simplex,  scarlatina  anginosa  and  scarlati?ta 
maligna. 

Symptoms.  A  mild  case  is  a  very  trivial  affection,  but  in  its 
severest  form  there  are  few  diseases  more  malignant. 

Onset  sudden  with  a  decided  chill  and  vomiting  (in  infants,  con- 
vulsions), pain  in  throat  followed  by  high  fever,  soon  reaching  105° ; 
a  rapid  pulse,  no  to  140  being  common.  At  the  end  of  twenty-four 
hours  a  bright  scarlet  rash  appears  on  the  neck  and  chest,  spreading 


40>  PRACTICE   OF   MEDICINE. 

over  the  entire  body  within  a  few  hours  ;  the  eruption  is  not  raised, 
there  is  no  intervening  heahhy  skin,  and  scattered  irregularly  are 
points  of  a  darker  hue.  With  the  appearance  of  the  eruption  occurs 
burning  heat  of  surface,  burning  in  the  throat  and  difficulty  in  deglu- 
iitio7i,  the  throat  on  inspection  presenting  the  appearance  of  a  catar- 
rhal \n^2imm.2i\.\on.  Tongue  at  first  furred,  later,  red,  with  prominent 
papillae — the  "  strawberry  tongue."  There  also  occnrs  headache, great 
restlessfiess,  and  in  severe  cases  delirium.     Diarrhoea  quite  common. 

On  the  fourth  or  fifth  day  the  fever  declines  by  lysis,  the  eruption 
fading,  and  on  the  fifth  or  eighth  day  desquamation  begins,  continu- 
ing for  a  week  or  more,  the  convalescence  being  slow,  the  patient 
etnaciated  and  pale. 

Scarlatifia  ajtgifiosa  are  cases  with  the  addition  of  great  inflamma- 
tion and  swelling  of  the  pharynx,  nose,  palate,  to7isils  and  neighbor- 
ing glands,  the  swollen  glands  pressing  upon  the  surrounding  parts, 
causing  difficulty  of  breathing  and  of  deglutition. 

Scarlatina  maligna  are  cases  with  decided  nervous  phenomena,  to 
wit :  coftvulsions,  deliriu?n  and  muscular  twitching,  the  temperature 
reaching  107°  to  110°,  the  pulse  rapid,  feeble  and  irregular,  the  erup- 
tion  delayed,  of  a  purplish  color,  and  in  patches. 

Sequelse.  Chronic  sore  throat;  conjunctivitis;  otorrhcea ;  chronic 
diarrhoea ;  subacute  rheumatism  ;  chorea  ;  endocarditis  ;  pleuritis  ; 
acute  Bright's  disease  and  cutaneous  dropsy. 

Diagnosis.  A  typical  case  should  cause  no  difficulty ;  the  high 
fever,  rapid  pulse,  sore  throat,  and  early  scarlet  erupti6n,  followed  by 
desquamation,  should  leave  no  doubt. 

Measles  ;  the  above  symptoms  are  absent,  and  catarrhal  symptoms 
present. 

Stnallpox  ;  eruption  on  the  third  day  in  spots,  changing  to  pustules 
with  secondary  fever. 

Dengue  or  break-bone  fever ;  absence  of  the  above  typical  symp- 
toms, and  presence  of  severe  pains  in  the  back. 

Diphtheria  ;  gradual  invasion,  great  prostration,  and  no  eruption, 
but  the  frequent  complication  of  scarlatina  and  diphtheria  must  be 
remembered. 

Meningitis  may  be  suspected  from  the  symptoms  of  scarlatina 
maligna;  the  epidemic  influence,  eruption,  and  rapid  pulse,  are 
points  of  difference. 

Prognosis.     Depends  upon  the  character  of  the  attack.     Never 


FEVERS.  41 

can  be  positive  of  the  result.  Mortality  ranges  from  ten  to  twenty- 
five  per  cent. 

Treatment.  As  with  other  eruptive  fevers  so  with  scarlatina  ; 
there  are  no  specific  remedies  by  means  of  which  it  can  be  arrested 
or  controlled.  Symptomatic  treatment  judiciously  applied,  however, 
may  afford  relief  and  diminish  the  fatality. 

The  indications  are  for  good  ventilation,  isolation,  disinfection, 
cooling  drinks,  action  upon  the  skin  and  light  nourishment. 

For  cases  with  \i\^  fever  and  rapidity  of  pulse,  aco7iitum,  digitalis, 
quinina  or  antipyritie ,  with  cool  sponging,  cold  bath,  douche  or  pack. 

If  the  surface  be  pale,  the  circulation  feeble,  and  the  eruption  tardy 
in  appearing,  benefit  will  follow  the  administration  of  tinctura  bella- 
do7incE,  gtt.  j-x,  according  to  age. 

For  scarlatina  anginosa,  internal  use  of  tinctura  ferri  chloridi  and 
potassii  chloratis,  and  stiimtlants.  Externally,  ice  or  cold  compresses, 
unless  they  cause  chilliness ;  if  so,  heat.  Astringent  gargles  and 
small  pellets  of  ice  dissolved  in  the  mouth  are  of  use.  The  throat 
and  nasal  cavities  are  kept  clean  and  the  breathing  relieved  by  the 
use  of  Dobell's  solution  used  in  a  hand  atomizer  every  hour. 

Dr.  J.  L.  Smith  warmly  lauds  the  following  mixture  for  cases  with 
decided  throat  symptoms  : — 

R  .     Acid  boracic, ^  ss 

Potass,  chlor.,     , ^ij 

Tinct.  ferri  chlor., f  5  ij 

Glycerinae, 

Syrupi, aa f^j 

Aquae,      f^ij-  M. 

SiG. —  One  tablespoonful  every  two  hours,  to  a  child  of  five  years. 

For  scarlatifia  maligna,  in  addition  lo  ferrtnn  and  qiiinina,  the  chief 
reliance  must  be  on  alcoholic  stimulants,  guiding  the  amount  by  their 
effects.  In  children  wine-whey,  milk-punch,  and  egg-nog  are  eligible 
for  the  administration  of  stimulants  and  nourishment. 

For  the  pruritus,  the  local  use  of  oils  or  fats  in  some  form  affords 
great  relief,  the  following  formula  being  most  efficient,  as  well  as  a 
disinfectant : — 

li .     Acidi  carbolici, gr.  x-xxx 

Vaseline, ^iij.  M. 

SiG. — To  be  applied  over  the  entire  surface  after  sponging  or  bath. 
Convulsiotis  result  from  the  high  grade  of  fever,  or  are  the  result  of 


42  PRACTICE  OF   MEDICINE. 

uraemia.  If  due  to  the  former  cause,  the  cold  bath  and  cold  affusion 
are  the  indications  ;  if  the  latter  cause,  the  inhalation  of  chloroformum 
is  indicated. 

For  the  headache,  disturbance  of  vision  and  cotna,  the  result  of 
uraemia,  free  purgation  and  diaphoresis  with  pilocarpus  are  to  be 
employed. 

Prof.  DaCosta  advocates  the  administration  of  ammonii  carbonas, 
in  small  doses  at  frequent  intervals,  to  prevent  the  liability  of  heart- 
clot,  and  for  its  salutary  influence  over  the  disease. 

It  is  claimed  that  a  characteristic  micrococci  is  found  in  the  blood, 
and  that,  consequently,  the  disease  can  be  favorably  influenced  by 
acidum  carbolicum,  thymol  or  acidum  boricum ;  an  eligible  way  of 
administering  acidum  carbolicum  is  the  syr.  ammonicE  pheftatis 
(Declat),  foss-foj,  four  to  six  times  daily. 

For  the  various  sequelcE,  the  treatment  is  the  same  as  if  they 
occurred  primarily,  jZ^/z^i-  tonics. 

The  disease  being  infectious,  every  means  should  be  taken  to  prevent 
its  spread,  to  wit :  isolation,  cleanliness,  disinfection  and  fumigation. 

Small  doses  of  quinina,  in  those  exposed,  is  said  to  prevent  or 
modify  the  severity  of  an  attack,  but  no  true  prophylactic  is  known. 

MEASLES. 

Ssmonyms.     Morbilli ;  rubeola. 

Definition.  An  acute  epidemic  and  contagious  disease  ;  charac- 
terized by  catarrhal  symptoms,  referable  to  the  naso-broncho -pul- 
monary mucous  membrane,  fever,  and  a  crimson  eruption  which 
terminates  by  desquamation. 

Cause.  A  specific  poison,  with  a  special  susceptibility  for  child- 
hood. Contagious  by  contact,  and  has  been  communicated  by  in- 
oculation. One  attack,  as  a  rule,  protects  from  a  second.  Incubation , 
ten  days. 

Pathological  Anatomy.  There  are  no  special  anatomical 
characters  exclusive  of  the  eruption,  which  is  considered  among  the 
symptoms  of  the  disease. 

Symptoms.  Onset  gradual,  irregular  chills,  fever,  the  tempera- 
ture rising  to  ioi°  or  102°,  muscular  soreness,  headache,  and  intense 
7iasal,  pharyngeal  and  laryngeal  catarrh  ;  on  the  evening  of  the 
second  day  a  decided  remission  takes  place  in  \.h.Q  fever,  the  catarrh 


FEVERS.  43 

continuing;  on  "dx^ fourth  day  occurs  an  eruption  of  a  crimson  color, 
on  the  face,  soon  spreading  over  the  body,  in  the  form  of  dots,  shghtly 
elevated,  which  coalesce  into  irregular  circles  or  crescents,  and  with 
the  appearance  of  the  eruption  \k\.Q.  fever  returns,  the  catarrh  is  aggra- 
vated, but  the  character  of  the  discharge,  instead  of  remaining  clear 
and  watery,  becomes  turbid,  thick,  and  yellowish,  and  extends  to  the 
bronchial  mucous  membrane.  About  the  ninth  day  (the  fourth  of 
the  eruption),  the  eruption  fades,  the  symptoms  abate,  and  slight 
desquamation  occurs.  Some  cough  and  catarrh  may  remain  for  a 
long  period. 

Black  measles,  sometimes  called  heinorrhagic  rubeola,  or  camp 
measles,  is  a  variety  occurring  in  camps  and  jails,  in  which  occur 
dangerous  chest  symptoms,  and  black  spots  or  petechise  from  deteri- 
orated blood,  and  severe  prostration. 

Rather  common  complications  are  tonsillitis,  lobar,  and  catarrhal 
pneumonia. 

Sequelae.  In  those  oi  strumoics  diathesis,  scrofula  or  phthisis  may 
develop. 

Diagnosis.  A  typical  case  begins  gradually,  with  chilliness,  nasal 
catarrh,  watery  eye,  and  fever,  which  decline  before  the  eruption, 
rising  afterward,  the  eruption  crescentic  in  shape,  and  of  a  crimson 
color. 

Scarlet  fever ;  absence  of  catarrh,  and  earlier  appearance  and  dif- 
ferent character  of  the  eruption  with  high  fever  and  rapid  pulse. 

ProgTlosis,  As  a  rule,  a  perfect  recovery.  If  phthisis  develop, 
the  prognosis  is  bad.     Black  measles,  the  majority  perish. 

Treatment.  No  specific.  Mild  cases  require  no  medicine,  simply 
regulating  the  diet  and  bowels,  and  cool  sponging ;  the  indications 
are  to  render  the  patient  as  comfortable  as  possible,  the  disease  pur- 
suing a  favorable  course  without  therapeutical  interference. 

If  the  febrile  reaction  is  high  the  following  soon  controls  it : — 

R  .     Tinct.  aconiti  rad., Tt\^  ss-j 

Spts,  aetheris  nitrosi, Tr\^  x-xv 

Liquor,  potassii  citrat., ad  .    .    .    .  f^j.  M. 

Every  two  hours. 

For  the.  pruritus  of  the  eruption,  the  local  use  of  oils  andyJz/j,  For 
catarrhal  symptoms,  inunction  of  the  nose,  neck,  and  chest  with  catn- 
phorated  oil  and  small  doses  of  pulv.  ipecac  et  opii,  at  bedtime ;  if  the 
catarrh  extends  to  the  bronchial  mucous  membrane,  expectorants. 


44  PRACTICE   OF   MEDICINE. 

During  convalescence,  for  the  strumous,  protect  from  exposure,  and 
administer  oleum  viorj-hucB  with  syr.  ferri  iodidi.  For  black  measles, 
bold  stimulation,  Wiih.  fefnan  and  qui7iina. 


ROTHELN. 

SynonyTQS.  Epidemic  roseola ;  German  measles ;  French 
measles ;  false  measles. 

Definition.  An  acute,  self-limited  disease  ;  characterized  by  mild 
fever,  suffused  eyes,  cough,  and  sore  throat,  enlargement  of  the  lym- 
phatic glands  of  the  neck,  and  a  rose-colored  eruption,  in  patches  of 
irregular  size  and  shape,  appearing  on  the  first  day. 

Cause.  Propagated  by  infection.  That  a  peculiar  germ  exists  is 
probable,  but  thus  far  it  has  not  been  isolated,  l7ictibaiio7i  from  one 
to  three  weeks. 

Symptoms.  Onset  sudden,  with  mild  fever,  suffused  eyes,  with 
little  or  no  coryza,  sore  throat,  and  enlargeme?it  of  the  cenncal glands, 
not  limited  to  those  about  the  angle  of  the  jaw,  as  in  scarlatina. 
Any  time  from  the  Jirst  to  the  fourth  day  appear  rose-colored  spots, 
size  of  a  pin  head,  slightly  elevated,  which  coalescing,  form  irregular 
shaped  and  sized  patches,  with  intervening  healthy  skin,  fading  on 
the  upper  part  of  the  body  while  just  appearing  on  the  lower.  Symp- 
toms all  terminate  within  a  week  by  lysis,  the  patient  showing  no  ill 
effects  from  the  attack. 

Diag'nosis.  From  scarlet  fever,  by  absence  of  high  fever,  the 
rapid  pulse,  the  color  and  character  of  the  eruption  and  the  sequelae. 

From  measles,  by  absence  of  intense  catarrhal  symptoms,  the  late 
appearance  of  eruption  and  not  of  a  crescentic  shape. 

Prognosis.     Most  favorable. 

Treatment.  Mild  laxatives  and  restricted  diet.  U  fever  high, 
saline  mixture.  For  itching  of  skin,  sponging  with  vinegar  and 
water. 

SMALLPOX. 

Synonym.     Variola. 

Definition.  An  acute  epidemic  and  contagious  disease ;  charac- 
terized by  severe  lumbar  pains,  vomiting,  and  an  initial  fever,  lasting 
from  three  to  four  days,  followed  by  an  eruption,  at  ^x^X.  papular,  then 
vesicular  and  afterwards  pustular ;  the  development  of  the  pustule 


FEVERS.  45 

being  accompanied  by  a  secondary  fez^er,  during  the  presence  of  which 
grave  comphcations  are  prone  to  occur. 

Causes.  A  specific  poison  whose  nature  is  unknown,  maintaining 
its  contagious  vitality  for  a  long  period.  There  is  no  period,  from  the 
initial  fever  to  the  final  desquamation,  when  the  disease  is  not  con- 
tagious, although  the  stage  of  suppuration  is  the  most  virulent.  One 
attack,  as  a  rule,  protects  from  a  second.  Vaccijiation  has  a  positive 
protective  influence  from  the  disease,  an  extensive  observation  having 
fully  proven  that  in  proportion  to  the  efficiency  of  vaccination  is 
the  rarity  and  mildness  of  variola.  Incubation,  fourteen  to  sixteen 
days. 

Pathological  Anatomy.  A  granular  and  fatty  degeneration 
occurs  in  the  liver,  spleen,  kidneys  and  heart.  The  pustules  are 
found  in  the  larynx,  trachea,  bronchial  tubes,  and  on  the  pleura. 

Varieties.  Discrete  ;  confluent ;  malignant ;  varioloid  or  modified 
smallpox. 

Symptoms.  Discrete  form.  Onset  sudden,  with  a  "i/z^/^^/r-^z"//, 
vomiting,  and  Sigomzing  pains  in  the  back,  shooting  down  the  limbs  ; 
fever,  in  short  time  rising  to  103°  or  104°  F.  ;  full,  stro7ig  and  rapid 
pulse,  ranging  from  100  to  130;  the  face  red,  eyes  injected,  intense 
headache  and  sleeplessness  •  delirium  and  convulsions  occur  at  times. 
During  the  third  day  the  characteristic  eruption  makes  its  appear- 
ance, first  on  the  forehead  and  lips,  consisting  of  coarse  red  spots  ; 
with  the  appearance  of  the  eruption  all  the  marked  symptoms  of  the 
fever  abate,  the  patient  feeling  quite  comfortable.  On  the  ffth  day 
of  the  disease  the  spots  become  papules;  on  \h&  sixth  day,  trans- 
formed into  vesicles,  which  are  soon  timbilicated ;  on  the  eighth  day  the 
vesicles  change  to  pustules  ;  on  the  fiinthday  the  pustules  are  entirely 
purulent,  and  each  surrounded  with  a  broad  red  band — the  halo  or 
areola,  the  face  becoming  swollen,  and  the  features  distorted  ;  on  the 
eleveiith  day,  pus  oozes  from  the  pustules,  and  drying,  forms  the  scab 
or  crust,  which,  on  the  seventeenth  to  twenty -first  day  drops  off,  leav- 
ing a  red,  ghstening  depression  or  pit,  soon  changing  into  a  white 
cicatrix.  With  the  formation  of  the  pustules  {eighth  day)  severe 
rigors  and  fever  set  in,  and  a  characteristic  odor  is  emitted,  all  the 
original  symptoms  returning  ;  this  seco7idary  fever  is  the  most  critical 
period  of  the  disease,  and  is  generally  attended  with  violent  delirium. 
In  favorable  cases  the  secondary  fever  subsides  after  three  or  four 
days,  and  convalescence  is  established. 


46  PRACTICE   OF   MEDICINE. 

Confiitent  smallpox  differs  from  the  discrete  in  the  greater  severity 
of  all  the  symptoms  and  the  marked  prostration  of  the  patient,  the 
eruption  appearing  during  the  second  day,  the  ^//^//^/t'j  coalescing  into 
large  patches,  causing  great  distortion  of  the  features. 

Malignant  smallpox  is  characterized  by  the  greater  intensity  and 
the  irregularity  of  the  symptoms,  death  resulting  before  the  character- 
istic eruption  appears,  by  convulsions  or  coma.  In  these  cases  hem- 
orrhages are  frequent  and  petechias  are  observed. 

Varioloid,  or  modified  smallpox,  is  the  form  modified  by  previous 
vaccination  or  by  a  former  attack  of  smallpox.  Its  course  is  shorter 
and  milder  than  the  other  forms,  the  eruption  appearing  a  day  later, 
and  is  not  attended  with  secofidary  fever. 

Complications.  During  the  course  of  the  secondary  fever  there 
is  a  great  tendency  to  grave  inflammations,  such  as  pleitritis,  pneu- 
mo7iitis  and  dysentery.  During  convalescence,  boils  and  abscesses  on 
the  skin  are  frequent. 

Diag"nosis.  Cannot  be  confounded  with  any  other  disease  if  it 
have  typical  symptoms,  such  as  chill,  vomiting,  pains  in  back  and 
legs,  high  fever  and  pulse,  all  declining  on  third  day,  when  the  erup- 
tion appears,  first  spots,  then  papules,  then  vesicles,  finally  pustules, 
drying  and  forming  crusts,  and  with  the  marked  secondary  fever. 

Prognosis.  Depends  upon  the  variety  of  the  attack,  the  age  of 
the  patient,  and  whether  vaccinated  or  not.  Discrete,  mortality  four 
per  cent. ;  confluent,  fifty  per  cent.  ;  malignant,  all  perish  ;  underyfz/^ 
years  and  ov  ox  forty  years,  fifty  per  cent.  die. 

Treatment.  No  specific ;  the  disease  will  run  its  course  under 
any  plan  of  medication,  although  cases  seem  to  do  better  if  acidum 
carbolicum,  thy??iol  or  the  sulphites  are  used. 

For  the  initial  fever  and  iho,  full  pulse,  relief  follows  the  use  of — 

R .     Tinct.  aconit.  rad  , gtt.  j-ij 

Spts.  aether,  nitrosi, '^^ss 

Liq.ammonii  acetat., f  3  ij 

Aqu£e, £3  iss.  M. 

Every  hour  or  two. 

Antipyrine  should  be  serviceable  in  this  stage,  not  only  for  the  fever, 
but  to  relieve  the  pains. 

If  headache  and  backache  are  intense,  hypodermic  injections  of 
morphina,  or  an  ice  bag  to  the  head  and  along  the  spine. 


FEVERS.  47 

For  sleeplessness  and  restlessness  or  early  deliriujn  full  doses  of 
potassii  bromidufn,  or  chloral. 

For  secondary  fever  the  best  remedy  is  quinina,  gr.  v,  every  three 
hours,  2inAior  cerebral  excitement  oi  this  period,  either  full  doses  of 
potassii  bromidum,  by  stomach,  or  the  following  by  rectum  : — 

R.     Chloral, gr.  xv-xx 

Mucil.  acacia, fgij 

Aquce, ^SU'  M* 

p.  r.  n. 

The  secondary  fever  being  pysemic  in  character,  the  depression 
should  be  anticipated  by  large  doses  of  tinct.  ferri  chloridi  and  judi- 
cious stiimilation,  brandy  in  tablespoonful  doses  being  most  efficient. 

From  the  onset,  milk,  eggs,  animal  broth,  oysters  and  beef  juice 
should  be  administered  every  three  hours.  Ice  is  always  grateful  and 
should  be  given  freely,  and  if  pustules  appear  in  the  mouth,  ice  should 
be  held  in  the  mouth  as  long  as  possible,  and  washes  oi  potassii 
chloras  or  acidum  carbolicuni  employed. 

The  disease  being  contagious,  isolation,  ve7itilation,  cleanliness  and 
disinfection  are  imperative. 

To  prevent  pitting  keep  patient  in  a  dark  room,  well  ventilated. 
Masks  of  some  unctuous  material,  thoroughly  applied,  to  exclude  the 
air,  have  a  beneficial  effect,  a  good  formula  being  R.  Ung.  hydrarg., 
pulv.  mara7itce,  eqtial parts,  ox  glycerit.  amyli,  painted  over  eruption, 
changing  to  tinct.  iodi  as  vesicles  are  about  to  develop.  Success  is 
claimed  by  a  number  of  observers  from  the  use  of  colloditim  applied 
once  or  twice  daily.  Cold  water  dressings  constantly  to  face  and 
hands  are  beneficial,  besides  allaying  heat,  pain  and  swelling.  Hot 
water  can  be  used  if  more  grateful. 


VACCINATION. 

Definition.  Inoculation  with  the  matter  of  vaccijtia  or  cow-pox 
— bovine  virus.  The  person  properly  vaccinated  is,  as  a  rule,  pro- 
tected from  an  attack  of  smallpox,  and  especially  from  a  severe  or 
fatal  attack. 

Vaccination  should  be  performed  at  least  twice  in  every  individual, 
to  wit :  during  infancy  and  txX  puberty  ;  and  it  is  safer  to  have  it  again 
performed  if  special  exposure  be  liable  to  occur. 


48  PRACTICE   OF   MEDICINE. 

In  practicing  vaccination  the  skin  should  be  rapidly  scraped  until 
the  true  skin  is  reached  and  is  ready  to  bleed,  the  lymph  being  then 
brushed  over  the  abraded  surface  ;  or,  instead,  making  three  or  four 
horizontal  and  transverse  cuts,  about  four  lines  long,  and  rub  the 
virus  over  them  ;  a  little  blood,  but  not  much  bleeding,  should  be 
caused. 

S3niiptonis.  If  the  vaccination  "  takes,"  on  the  third  day  a 
papule  appears  ;  on  the  sixth  day  a.  vesicle  has  formed,  with  a  central 
depression  ;  on  the  eighth  day  a.  pustule,  fully  formed  and  distended 
with  lymph,  with  a  reddish  areola,  which  becomes  very  wide.  The 
areola  begins  to  fade  on  the  te7iih  day,  the  pustule  begins  to  dry,  and 
by  iht  fourteenth  day  a  brown  mahogany  scab  or  crust  has  formed, 
which  is  detached  about  the  twenty- third  day.  The  cicatrix  is  circu- 
lar, depressed,  radiated  and  foveated,  becoming,  after  a  time,  paler 
than  the  surroundingr  intesrument. 

During  the  course  of  a  vaccination,  more  or  less  constitutio  nal  dis- 
turbance occurs,  especially  in  children. 

Ecsematous  and  papular  eruptions  often  develop  in  strumous  chil- 
dren, for  which  the  virus  is  unjustly  held  responsible. 


VARICELLA. 

S37TLonyin.     Chicken-pox. 

Definition.  A  mild,  slightly  contagious,  febrile  affection ;  char- 
acterized by  a  moderate  fever,  and  the  appearance  of  a  vesicular 
eruption,  drying  up  and  falling  off  in  from  three  to  five  days. 

Cause.  A  peculiar  poison  ;  attacking  only  children  ;  occurring 
sporadically  and  as  an  epidemic. 

Symptoms.  Moderate /^2/<?r,  thirst,  anorexia  and  constipation, 
followed  by  the  eruption  of  vesicles,  which  rapidly  dry,  and  within 
the  week  drop  off,  leaving  a  slight  pit.  Pustules  almost  never 
occur.  Symptoms  are  so  slight,  that,  were  it  not  for  the  vesicles, 
the  affection  would  be  often  overlooked.  The  eruption  appears  on 
the  trunk  and  extremities,  very  rarely  on  the  forehead  and  in  the 
mouth. 

Prognosis.     Most  favorable. 

Treatment.  Entirely  symptomatic.  If  vesicles  on  the  face, 
efforts  may  be  used  to  prevent  pitting. 


FEVERS.  49 

ERYSIPELAS. 

Synonyms.  Erysipelatous  dermatitis  ;  the  rose  ;  St.  Anthony's 
lire. 

Definition.  An  acute,  specific,  infectious  disease  ;  characterized 
by  a  fever  of  low  type,  and  a  peculiar  inflammation  of  the  skin,  gen- 
erally of  the  neck  and  face.  This  inflammation  exhibits  a  marked 
tendency  to  spread,  to  induce  serous  infiltration  and  suppuration  of 
the  areolar  tissue,  and  to  affect  the  lymphatic  vessels  and  glands. 

Cause.  A  poison,  the  nature  of  which  is  unknown.  Feebly  con- 
tagions. One  attack  predisposes  to  another.  The  etiology  of  idio- 
pathic (medical)  and  traumatic  (surgical)  erysipelas  are  identical. 

Symptoms.  Onset  sudden  ;  a  chill,  followed  by  fever,  which 
soon  reaches  104°  or  10"^°,  frequent  pulse,  100  to  130,  coated  tongue, 
nausea  and  vojniting,  severe  pains  in  the  limbs,  with  epistaxis  in 
adults  and  convulsions  in  children,  and  often  diarrhoea. 

Delirium  is  frequent,  and  in  those  of  alcoholic  habits  it  resembles 
delirium  tremens. 

The  eruption  soon  follows  the  chill,  beginning  in  red  spots,  which 
rapidly  coalesce  and  spread ;  a  sense  of  heat,  tension  and  tingling  is 
caused  by  ^ho.  great  cedema,  which  presents  a  tense,  shi7iy  appearance, 
the  swelling  being  so  great  at  times  as  to  close  the  eyes  and  distort 
the  features.  In  many  cases  small  vesicles  develop,  which  may 
coalesce,  forming  blebs,  of  considerable  size,  containing  a  clear  yellow 
serum.  After  five  or  six  days  the  eruption  begins  to  subside,  the 
symptoms  abate,  the  part  affected  becomes  tender,  and  there  is  mod- 
erate desquamation. 

During  the  height  of  the  attack  albumin  appears  in  the  urine,  so 
that  the  possibility  of  tircemic  symptoms  must  be  remembered. 

When  extensive  infiltration  into  the  areolar  tissue  occur,  the  swelling 
and  tension  become  greater,  and  it  is  termed  phlegmonous  erysipelas. 

When  the  eruption  spreads  to  different  parts  of  the  body,  it  is 
termed  erysipelas  ajnbulans. 

Complications.  Thrombosis  of  cerebral  capillaries  or  sinuses, 
or  as  it  is  sometimes  called,  "erysipelas  of  the  brain,"  is  explained 
by  the  intimate  anatomical  connection  of  the  facial  vein  with  the 
pterygoid  plexus  and  cavernous  sinus. 

(Edematous  laryngitis,  from  extension  to  the  larynx. 

Pneumonia,  pleurisy  and  meningitis  are  frequent  complications. 
4 


50  PRACTICE   OF   MEDICINE. 

Diag'nosis.  Not  difficult.  The  fever,  early  spreading  eruption, 
with  burning,  swelling,  tension  and  tingling,  and  albuminous  urine, 
separate  it  from  the  other  eruptive  fevers  and  erythema. 

Prog'nosis.  Usually  favorable.  Unfavorable  if  it  attack  drunk- 
ards ;  if  it  becomes  gangrenous  ;  if  thrombosis  of  sinuses  occur,  or  if 
it  extends  to  the  larynx. 

The  convalescence,  even  from  the  mildest  attack,  is  slow,  the 
patient  continuing  weak  and  anaemic  for  a  long  time. 

Treatment.  Mildest  cases  only  require  a  laxative,  nourishing 
diet,  and  locally  vaseline  or  bismuth  oleat.,  to  modify  the  heat  and 
burning. 

Prof.  Da  Costa  strongly  urges  the  use  oi  free purgatiori  before  the 
use  of  the  remedies  usually  administered. 

According  to  Reynolds,  aco?iitum  will  cut  short  an  attack.  He 
administers  Ti:\,  %-],  every  fifteen  minutes  for  the  first  two  hours  ;  then 
in  hourly  doses,  until  the  surface  is  moist  and  the  temperature  lowered. 
The  author  corroborates  this  plan,  from  a  personal  experience. 

In  severe  cases,  tinct.  ferri  chlor.,  gtt.  xx-xxx,  every  third  hour, 
well  diluted.  Also  qici7iina  in  gr,  ij,  every  third  hour.  Ext.  bella- 
donnce,  gr.  % ,  added,  with  benefit.  The  diet  from  the  onset  should 
be  of  the  most  nourishing  character,  and  administered  at  regular 
intervals.  Dr.  Waugh  strongly  lauds  extractum  pilocarpi fiuidwn  in 
erysipelas. 

Prof.  Da  Costa  reports  excellent  results  in  cases  with  rapid  spread- 
ing \.^Vi^Q.x\.Q.^ ,  from  the  use  oi  pilocarpijicE  hydrochloras,  gr.  yi,  hypo- 
dermically  or  ext.  pilocarpi fluidum,  gtt.  xx-xl,  every  two  hours.  Or 
good  results  are  obtained  in  a  fair  number  of  cases  from  potassii 
iodidum. 

Cerebral  symptoms,  stimulants,  opium  and  chloral. 

Extension  to  throat,  argenti  nitras,  brushed  over  parts.  If  symp- 
toms of  oedema  of  the  glottis  develop,  tracheotomy  is  indicated. 

Locally,  soothing  applications  are  indicated,  to  wit :  Vaseline,  ung. 
zinci  oxidi,  ol.  oHvce  cum  glycerince,  bismuth  oleat.  or  U7igt.  hydrar- 
gyrum. 

In  phlegmonous  variety,  argenti  nitras,  ^j,  spts.  cetheris  7iitrosi, 
3ij,  brushed  over  and  beyond  the  affected  part,  with  the  internal  use 
of  large  doses  of  quinina,  ferrum  and  stimulajits. 


FEVERS.  51 

DENGUE. 

Synonyms.     Break-bone  fever  ;  neuralgic  fever  ;  dandy  fever. 

The  word  dengue  is  pronounced  dangay. 

Definition.  An  acute,  epidemic,  febrile  disease,  consisting  of 
two  paroxysms  of  fever  with  an  intermission.  The  first  paroxysm 
is  characterized  by  high  fever,  distressing  pains  in  the  joints  and 
muscles,  and  a  peculiar  eruption  ;  the  second  paroxysm  is  charac- 
terized by  a  milder  fever,  an  eruption  of  different  character,  attended 
with  intense  itching,  by  some  recurrence  of  the  joint  pains,  and  by 
debility. 

Cause.  Unknown;  but  it  is  evident  that  a  peculiar  condition  of 
the  atmosphere  has  some  influence  in  its  development. 

Symptoms.  Onset  sudden— ^^z/*?;-,  103°  to  105°,  intense  headache, 
burning  pains  in  the  temples,  backache,  severe  aching  and  swelling  of 
the  joi7its  and  stiffness  of  7miscles,  nausea,  vomiting,  constipation 
and  the  appearance  of  a  rash,  resembling  scarlatina,  from  which  the 
disease  has  been  mistaken  for  scarlatinal  rheumatism.  After  some 
hours  to  two  or  three  days,  a  distinct  intermission  obtains,  of  one  or 
two  days'  duration. 

The  onset  of  the  second  paroxysm  is  also  sudden,  but  the  symp- 
toms are  much  less  severe,  although  the  patient  is  greatly  debilitated  ; 
it  is  at  this  time  that  the  characteristic  eruption  appears,  being  either 
erythematous  or  rubeolous,  and  attended  with  intense  itching,  remaining 
for  about  two  days,  when  desquamation  occurs  and  convalescence  is 
established,  but  is  prolonged  by  the  great  debility  of  the  patient. 
Average  duration  of  the  disease  eight  days.     Relapses  are  common. 

Diagnosis.  Most  apt  to  be  mistaken  for  acute  articular  rheiuna- 
tism,  especially  during  the  first  paroxysm,  but  the  course  of  the  dis- 
ease and  the  epidemic  influence  should  prevent  such  an  error. 

The  eruption  might  mislead  for  scarlet  fever  or  measles,  were  it 
not  for  the  severe  joint  and  muscular  pains. 

Prognosis.     Favorable. 

Treatment.     No  specific.     Entirely  symptomatic. 

At  the  onset,  free  purgatioji  and  diaphoresis. 

For  \he  fever,  quitiina,  gr.  v  every  five  hours,  or  ajitipyrine ,  gr.  x-xx, 
repeated  p.  r.  n. 

For  the  paijis,  opium  or  acidum  salicylicum. 

For  the  itchi?tg,  lotion  of  acidum  carbolicum. 


52  PRACTICE   OF   MEDICINE. 

DISEASES  OF  THE  MOUTH. 


CATARRHAL  STOMATITIS. 

Synon37TQS.  Simple  stomatitis  ;  erythematous  stomatitis  ;  catarrh 
of  the  mouth. 

Definition.  An  acute  catarrhal  inflammation  of  the  whole  or  a 
portion  of  the  mucous  membrane  of  the  mouth  and  tongue,  charac- 
terized by  pain,  redness,  swelling  and  disordered  secretion.  Most 
common  in  infants  and  children.  Chronic  stomatitis  occurs  mostly 
in  adults,  the  result  of  alcoholic  or  tobacco  excesses. 

Causes.  Introduction  of  hot  and  irritating  substances  into  the 
mouth  ;  difficult  dentition;  secondary  to  disorders  of  the  stomach,  to 
measles,  scarlet  fever  and  variola. 

Pathological  Anatomy.  The  buccal  mucous  membrane  and 
tongue  have  a  dark  red  appearance,  are  much  swollen,  the  tongue 
often  appearing  as  if  too  broad  to  lie  between  the  teeth,  the  sides 
showing  the  impressions  of  the  teeth  ;  the  secretions  are  at  first  les- 
sened, afterward  increased,  a  turbid  mucus  covering  the  cheeks,  gums 
and  tongue,  thus  giving  a  coated  tongue. 

Symptoms.  Oral  catarrh  begins  with  a  burning,  smartifig  pain, 
and  tejision  in  the  mouth,  in  those  old  enough  to  describe  their  suffer- 
ing. Very  young  children  refuse  to  nurse  or  allow  their  mouth  to  be 
touched,  have  slight  fever,  disordered  stomach,  ?irQ  fretful  2iT\d  sleep- 
less, craving  cooling  drinks. 

The  sense  of  taste  is  blunted,  and  there  is  usually  an  unpleasant 
bitter  taste  in  the  mouth. 

If  the  catarrh  becomes  chronic,  the  breath  has  a  fetid  odor  and  the 
tongue  is  coated  in  the  morning,  the  taste  is  disordered,  and  there  is 
generally  more  or  less  depression  of  spirits. 

Diagnosis.  If  the  buccal  cavity  be  examined,  the  condition  is 
readily  discerned. 

Prognosis.     Recovery  is  the  rule  for  the  acute  variety. 

The  chronic  cases  are  usually  due  to  the  use  of  tobacco  or  alcohol, 
and  are  only  modified  by  the  absolute  withdrawal  of  the  exciting 
cause. 

Treatment.  The  most  important  point  in  the  treatment  is  the 
removal  of  the  exciting  cause,  attention  to  the  secretions  and  diet,  and 


DISEASES   OF   THE   MOUTH.  53 

Locally — 

R .     Sodii  boratis, 5  iss 

Aquas  destillat.. f,^j 

Mel.  rosse, f^j. 


FOLLICULAR  STOMATITIS. 

Synonyms.     Aphthae  ;  vesicular  stomatitis  ;  croupous  stomatitis. 

Definition.  An  acute  inflammation  of  the  follicles  and  mucous 
membrane  of  the  mouth  and  tongue,  characterized  by  a  fibrinotis  or 
croupous  exudatio7i ;  the  exudation  first  appearing  in  isolated  spots 
{aphthcE  discrete),  afterward  coalesciiig,  and  forming  large  and  irregu- 
lar-sized patches  {aphthca  co7ifluens^,  which  rupture,  leaving  an  ulcer, 
which  slowly  heals. 

Causes.  A  disease  principally  of  childhood.  Difficult  dentition  ; 
disorders  of  digestion  ;  uncleanliness,  such  as  neglect  to  rinse  the 
child's  mouth  after  nursing ;  with  measles  and  diseases  of  the  buccal 
cavity. 

Pathological  Anatomy.  Begins  as  a  small,  whitish  papulo- 
vesicular elevation,  semi-transparent,  hard  and  tender,  with  a  distinct 
red  zone  about  their  base ;  there  may  be  as  few  as  six  or  as  many  as 
twenty ;  they  may  remain  isolated  {aphthcB  discrete)  or  coalesce 
{aphthcB  confiuens) ;  they  are  regarded  as  either  a  peculiar  deposit  or 
a  local  croupous  exudation.  After  a  day  or  two  they  rupture,  leaving 
an  irregular  white  or  grayish  ulcer,  which  slowly  heals.  The  seat  of 
the  affection  is  the  internal  surface  of  the  lips  and  cheeks,  the  gums, 
tongue  and  roof  of  the  mouth. 

Symptoms.  In  infants  the  pain  is  so  severe  that  the  child 
refuses  to  nurse.  In  older  children,  _^rtm  from  talking,  mastication, 
and  deglutition.  Salivation  is  marked,  the  saliva  dribbling  from  the 
mouth.  There  is  sWght feveriskftess ,  fretfulness  and  sleepless7iess. 
Digestion  is  impaired,  and  quite  commonly  diarrhcea  occurs.  A  dis- 
agreeable, penetrati?ig  odor  escapes  from  the  buccal  cavity. 

Diagnosis.  Impossible  to  confound  with  any  other  affection  if 
the  buccal  cavity  is  examined. 

Prognosis.     Always  favorable. 

Treatment.  Removal  of  the  exciting  cause.  Attention  to  the 
dietary  and  the  secretions  is  paramount. 

Internally,   excellent  results   follow   the   use   of  potassii  chloras, 


54  PRACTICE    OF    MEDICINE. 

gr.  j-iij,  every  three  or  four  hours,  according  to  the  age.     Protracted 
cases  require  tonic  doses  of  quhiincE  sulphas. 

Locally,  good  results  are  obtained  from  strong  solutions  of  poiassii 
chloras,  infusum  coptis  or  bismuth,  applied  directly  to  the  ulcers. 


ULCERATIVE  STOMATITIS. 

Synonyms.     Diphtheritic  stomatitis  ;  gingivitis  ulcerosa. 

Definition.  An  acute  diphtheritic  inflammation  of  the  mucous 
membrane  of  the  mouth,  continuing  until  extensive  and  unhealthy 
tilceratio7i  occur.  It  usually  begins  on  the  margin  of  the  lower  gums, 
and  often  extends  to  the  lips,  cheeks  or  tongue. 

Causes.  Usually  seen  in  children  only.  Most  frequently  in  the 
families  of  the  poor,  the  result  of  unfavorable  hygienic  surroundings, 
personal  uncleanliness  and  poor  food.  Often  seen  in  those  reduced 
by  severe  acute  disease.  Perhaps  contagious,  as  epidemics  are  not 
rare. 

Pathological  Anatomy.  The  gutns  first  appear  congested, 
swollen,  bleeding  readily  and  separated  from  the  teeth  ;  soon  a  firmly 
adherent  deposit  in  the  form  of  patches  appears,  at  first  whitish, 
speedily  becoming  gray  or  even  black,  from  disintegration,  becoming 
soft  and  pulpy,  the  separated  slough  leaving  irregular-shaped  ulcers, 
with  raised  margins  from  oedema  of  the  surrounding  tissue.  They 
are  not  deep,  and  their  surface  is  covered  with  a  pulpy,  yellowish 
substance.  The  morbid  process  usually  extends  to  the  inner  side  of 
the  lips,  cheeks,  and  to  the  tongue. 

Symptoms.  Pain  constantly,  aggravated  by  mastication  or 
deglutition  :  food  and  drink  must  be  of  the  blandest  character.  The 
mouth  is  hot,  the  saliva  dribbles  away,  mixed  with  blood  and  shreds 
of  puipy  ?natter,  the  breath  is  fetid,  the  appetite,  digestion,  and  bowels 
disordered.     The  patient  is  feverish,  fretful  and  sleepless. 

There  is  always  enlargement  and  tenderness  of  the  submaxillary 
glands. 

The  affection  is  often  associated  with  entero-colitis. 

Diagnosis.  Apt  to  be  confounded  with  gangrenous  stomatitis, 
than  which,  however,  there  is  less  constitutional  symptoms  and  a 
slower  course  of  the  malady. 

Prognosis.     Favorable.     If  promptly  and  properly   treated,  the 


DISEASES   OF   THE   MOUTH.  55 

ulcerated  surface  rapidly  heals,  although  quite  commonly  some  teeth 
are  lost. 

Treatment.  The  etiology  of  the  affection  must  be  borne  in  mind 
and  remedied.  Strict  attention  to  the  diet,  to  the  secretions,  and 
absolute  cleanliness. 

Interiially,  the  prompt  use  of  potassii  chloras,  gr.  j-v,  frequently 
repeated,  often  acts  like  a  specific.  The  general  health  often  calls 
for  quinina,  ferrum  and  stimulants. 

Locally,  a  strong  solution  oi potassii  chloras,  or  keeping  the  ulcer 
covered  with  bismuth,  or  frequent  applications  oi  alwnen  exsiccatiim 
are  valuable.  Cases  which  resist  these  remedies  should  have  applied 
the  following  combination,  proposed  by  the  late  Dr.  Dewees  : — 

U .     Cupri  sulphat., gr.  x 

Pulv.  cinchonse  opt., .    ^ij 

Pulv.  g.  arab., 5J 

Mel.  commun., f  3  ij 

Aquae  font., f.^  iij-  M. 

Ft.  sol. 
SiG. — The   ulceration  to  be  touched  twice  daily,  with  the  point   of  a 
camel's- hair  pencil. 

If  a  spreading  tendency  occur,  the  application  of  argenti  nitras 
dihctus,  or  a  diluted  solution  of  acidtim  nitricum  is  indicated. 


THRUSH. 

Sjrnonyms.     Muguet;  sprue;  white  mouth. 

Definition.  An  inflammation  of  the  mucous  membrane  of  the 
mouth,  associated  with  or  caused  by  the  growth  of  a  parasitic  piatit, 
the  o'idium  albicans  ;  characterized  by  pain,  disorders  of  digestion  and 
of  the  bowels. 

Causes.  The  development  of  the  thrush-fungus,  oidium  albicans, 
is  promoted  by  all  those  conditions  designated  as  unhygienic,  by  de- 
bilitated conditions  of  the  general  system,  and  by  neglect  to  thor- 
oughly rinse  the  mouth  after  nursing  or  bottle  feeding. 

The  age  is  considered  a  predisposing  cause,  seldom  being  seen 
after  two  years  of  age.  In  adults,  only  toward  the  last  stages  of  can- 
cer or  consumption. 

Pathological  Anatomy.  The  mucous  membrane  of  the  mouth 
assumes  a  dark  red  appearance  in  isolated  patches,  on  which  whitish 
Poifits  appear,  which  rapidly  coalesce  into  large  areas.     They  closely 


56  PRACTICE   OF    MEDICINE. 

resemble  curdled  milk,  from  their  soft  consistency.  These  whitish 
points  consist  of  epithelium  and  fat,  in  which  are  embedded  the 
sporules  and  filaments  of  the  fungus. 

The  deposit  first  appears  about  the  angles  of  the  mouth,  soon 
extending  to  all  parts  of  the  cavity,  often  to  the  pharynx  and 
oesophagus. 

The  mouth  is  usually  swollen  and  tender,  the  breath  often  fetid. 

Symptoms.  Pain,  aggravated  by  nursing  or  mastication.  The 
lips  are  swollen,  the  saliva  is  i?icreased,  the  breath  hot  and  somewhat 
fetid.  There  is  usually  increased  temperature,  Diarrhcea  is  frequent, 
the  stools  green  and  sour,  causing  an  erythema  of  the  buttocks. 

Diagnosis.  The  curd-like  appearance  of  the  deposit,  showing  the 
presence  of  parasites  upon  microscopical  examination,  will  prevent 
error. 

Prognosis.  Favorable,  unless  occurs  toward  the  termination  of 
exhausting  diseases. 

Treatment.     Absolute  cleanliness  of  the  mouth  is  all  important. 

Internally,  remedies  should  be  directed  to  the  removal  of  the  dis- 
orders of  the  gastro-intestinal  tract. 

Prompt  relief  has  followed  the  use  of  sodii  hyposuiphitis  saturat. 
sohit.,  gtt.  iij-x,  every  two  or  three  hours,  and  the  local  application 
of  the  same  solution. 

Locally,  solutions  of  sodii  boras  often  answer  every  indication,  the 
best  vehicle  being  glycerinu7n,  and  not  7?tel  or  saccharum,  a  good 
formula  being — 

R .     Sodii  boratis, 3  j 

Glycerini, f^ij 

Aquae, ,^  vj.  M. 

SiG. — Thoroughly  applied  four  or  five  times  daily,  and  continued  for  a 
week  after  the  disappearance  of  the  affection. 


GLOSSITIS. 

Definition.  An  inflammation  of  the  parenchyma  of  the  tongue  ; 
characterized  by  great  swelHng  of  the  organ,  with  difficult  mastication, 
deglutition  and  vocaHzation. 

The  affection  may  be  either  acute  or  chronic. 

Causes.  The  acute  variety  is  usually  the  result  of  some  direct 
irritation    to   the  tongue,  such    as    direct  injury,  contact    of  boiling 


DISEASES   OF   THE   MOUTH.  57 

liquids,  the  action  of  acrid  or  corrosive  substances,  or  the  sting  of  the 
tongue  by  an  insect,  such  as  the  bee  or  wasp. 

The  chrojiic  variety  is  generally  circumscribed  ;  it  may  follow  the 
acute  ;  be  due  to  the  sharp  edges  of  the  teeth,  or  the  use  of  a  tobacco 
pipe. 

Patholog'ical  Anatoray.  Acute  glossitis  begins  with  intense 
hyperasmia,  redness  and  swelling  of  the  organ  ;  the  size  often  be- 
comes so  great  that  the  tongue  is  too  large  for  the  mouth,  and  thus 
protrudes  between  the  teeth ;  its  surface  is  covered  with  a  thick  secre- 
tion, and  it  becomes  a  pale  or  grayish  color.  The  swelling  may 
rapidly  decline,  or  abscesses  may  form,  which  leave  a  more  or  less 
decided  depressed  cicatrix. 

Chronic  glossitis  occurs  usually  along  the  edges  of  the  organ,  the 
cicatricial  changes  being  in  circumscribed  hard  spots.  If  the  entire 
tongue  is  affected  with  chronic  inflammation,  the  action  is  superficial, 
and  has  been  termed  "psoriasis  of  the  mouth." 

Symptoms.  Acute  glossitis  begins  rather  abruptly  with  fever, 
increased  pulse,  restlessness,  anxiety,  enlargement  of  the  tongue,  a  sen- 
sation of  heat  in  the  mouth,  with  pain,  and  increased  flow  of  saliva. 
Mastication  and  deglutition  become  difficult,  if  not  impossible,  the 
voice  muffled  and  dyspncea  decided.  The  glands  at  the  angles  of  the 
jaw  are  enlarged,  which,  in  turn,  compress  the  vessels  of  the  neck. 

When  suppuration  supervenes,  the  constitutional  symptoms  become 
severe  and  the  oral  symptoms  are  intensified.  Death  has  occurred 
from  suffocation  in  severe  cases. 

Chronic  glossitis  presents  pain  as  the  chief  symptom,  aggravated 
by  movements  of  the  organ. 

Diag'nosis.  The  rapid  course  oi  acute  glossitis  should  prevent  its 
being  mistaken  for  any  other  affection. 

Chro7iic  glossitis,  if  severe,  might  be  mistaken  for  cancer  of  the 
tongue,  although  the  slow  and  mild  progress  of  the  former  contrasts 
strongly  with  the  rapid,  severe  and  painful  course  of  the  latter,  with 
its  marked  constitutional  symptoms. 

Prognosis.  Acute  glossitis  usually  terminates  in  recovery  within 
a  week,  although  the  danger  of  suffocation  must  always  be  remem- 
bered. 

Chronic  glossitis  is  an  incurable  malady  in  the  majority  of  in- 
stances. 

Treatm.ent.  For  acute  glossitis  prompt  measures  are  demanded. 
5 


58  PRACTICE   OF   MEDICINE. 

For  the  fever  and  rapid  pulse,  fmctiira  aconiti,  gtt.  j  to  iij  every 
half  hour  or  hour  until  its  physiological  effects  are  produced. 

For  the  ejilargenient  of  the  organ,  either  ice  constantly  applied  in- 
ternally and  externally,  at  the  angles  of  the  jaw,  or  the  persistent  use 
of  Jiot  luater  held  in  the  mouth  and  externally ;  if  prompt  relief  does 
not  follow  these  measures,  or  if  the  case  is  an  aggravated  one,  the 
prompt  deep  scarification  of  the  tongue  must  be  resorted  to. 

If  abscesses  form,  promptly  open  them  and  administer  quinina. 

If  suffocation  appear  imminent,  tracheotomy  must  be  performed. 

For  chronic  glossitis,  the  removal  of  the  exciting  cause  and  the  local 
use  of  argenti  nitras  to  the  ulcerated  edges. 

"  For  psoriasis  of  the  tongue,"  the  local  use  oi  argentum  or  acidiwi 
carbolicum. 

The  general  health  must  always  receive  due  attention. 


DISEASES  OF  THE  STOMACH. 


ACUTE  GASTRIC  CATARRH. 

Synonyms.  Acute  mild  gastritis  ;  gastric  fever  ;  bilious  fever  ; 
acute  indigestion  ;  subacute  gastritis. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  stomach  ;  characterized  by  feverishness,  loss  of  appetite, 
nausea,  with  occasional  vomiting,  painful  digestion,  irregularity  of  the 
bowels,  and  in  severe  attacks,  vertigo  {stomachic  vertigo^. 

Causes.  Deficient  quantity  of  or  quality  in  the  gastric  juice. 
Errors  in  diet,  insufficient  mastication  of  food,  swallowing  liquids 
which  are  either  too  hot  or  too  cold,  and  particularly  the  abuse  of 
alcoholic  liquors. 

Often  secondary  to  infectious  diseases,  such  as  scarlet  fever,  measles, 
smallpox,  diphtheria,  and  typhoid  fever.  Occasionally  the  result  of 
sudden  changes  of  temperature. 

Pathological  Anatomy.  The  mucous  membrane  is  irregularly 
congested  and  engorged,  and  covered  with  a  grayish,  semi-transparent 
and  te7iacious  ?m(cus,  having  an  alkaline  reaction.  The  true  gastric 
juice  is  secreted  in  lessened  amount  or  is  entirely  suspended. 


DISEASES   OF   THE   STOMACH.  59 

Symptoms.  At  first,  loss  of  appetite,  at  times  disgust  for  food^ 
heavily  coated  tongue,  bad  taste  and  breath,  persistent  nausea,  and 
at  times  voyniting,  first  of  undigested  food,  then  viscid  mucus,  acid 
and  bitter,  and  finally,  bilious  matter ;  moderate  irritative  fever  is 
present,  with  headache,  considerable  thirst  and  flashes  of  heat  with 
sensations  of  burning  in  the  palms  of  the  hands  and  soles  of  the  feet ; 
acid  drinks  eagerly  sought  after ;  digestion  imperfect,  giving  rise  to 
pain,  tenderness ,  feeling  of  weight  and  eructations ;  bowels  often 
loose,  sometimes,  however,  constipated.  Vertigo  with  pain  in  the 
nucha,  is  a  prominent  symptom  in  many  cases,  causing  great  anxiety 
and  depression  of  spirits.  The  urine  is  scanty,  containing  lithates 
and  pigment. 

The  symptoms  are  aggravated  by  errors  in  diet,  and  if  saccharine 
or  fatty  articles  are  taken,  heartburn  occurs. 

Towards  the  termination  of  an  attack,  herpetic  eruptions  appear 
about  the  mouth. 

Diag'nosis.  Acute  gastric  catarrh  with  fever  may  be  confounded 
with  remittent  and  typhoid  fever  of  the  first  week,  but  all  doubts  will 
disappear  as  these  maladies  develop. 

The  vertigo  may  be  mistaken  for  cerebral  disease,  but  the  disappear- 
ance of  this  symptom  when  stomachic  treatment  is  inaugurated 
removes  all  apprehension. 

Prognosis.  Favorable.  Duration  about  a  week  ;  recovery  slow, 
even  under  treatment,  as  far  as  perfect  digestion  is  concerned. 

Treatm.ent.  Give  the  stomach  as  complete  rest  as  possible.  If 
the  stomach  is  overloaded,  an  ipecac  einetic  is  indicated,  or  if  vomit- 
ing has  begun,  it  may  be  encouraged  by  swallowing  large  draughts  of 
hot  water,  which  will  act  as  a  sedative  if  the  stomach  be  empty. 
Irritability  of  the  stomach  is  readily  controlled  by — 

R .     Hydrarg.  chlor.  mitis, gr.  ^^-^^ 

Sodii  bicarb., gr.  ij 

Pulv.  aromat., gr.  v.  M. 

Every  two  hours, 

which  has  the  additional  advantage  of  relieving  the  bowels,  or — 

R.     Bismuthi  subnit., gr.  xv 

Acid,  hydrocyanici,  dil., TT\^ij 

Mucil.  acacise, f^ss 

Aq.  menth.  pip., f^iss.  M. 

SiG. — Every  two  or  three  hours. 


60  PRACTICE   OF   MEDICINE. 

Many  cases  are  rapidly  benefited  by  one  or  two  drop  doses  of  tinc- 
tura  micis  vomicis  every  hour. 
Weak  alkaline  vimeral  waters  or  liqiwr  calcis  sh.o\\\d.  be  freely  used. 
After  the  acute  symptoms  have  subsided — 

R.     Strychninae  sulph., g''-^V 

Acid,  hydrochlor.  dil., gtt.  x 

Tinct.  gent,  co., f^j.  M. 

Before  meals,  will  improve  the  appetite  and  digestion. 


ACUTE  GASTRITIS. 

Synonym.    Toxic  gastritis. 

Definition.  An  acute  and  violent  inflammation  of  the  mucous, 
submucous  and  muscular  coats  of  the  stomach,  with  loss  of  tissue  ; 
characterized  by  great  pain,  constant  vomiting  of  blood-streaked  or 
bloody  mucus  and  symptoms  of  collapse. 

Causes.  Ingestion  of  irritant  and  corrosive  poisons,  such  as  the 
mineral  acids,  arsenic,  corrosive  sublimate,  copper  and  carbolic  acid. 

Pathological  Anatomy.  The  mucous  membrane  is  vividly 
red  and  injected,  more  marked  at  some  portions  than  at  others  ;  it  is 
soft  and  friable  ;  erosions  are  irregularly  scattered,  and  the  sub- 
mucous, muscular,  and  at  times  serous  coats  show  decided  destructive 
changes.  The  gastric  tubules  are  destroyed  in  large  numbers.  In 
many  cases  the  oral  mucous  membrane  presents  signs  of  severe 
inflammation. 

Symptoms.  Immediately  or  soon  after  swallowing  the  irritant 
there  ensues  a  deadly  nausea,  with  rapid  and  persistent  vomiting ; 
first,  of  the  contents  of  the  stomach  acted  upon  by  the  poison,  after- 
ward, shreds  of  mucous  membrane  and  blood  clots ;  there  are  also 
present  great  anxiety  and  depression,  a  weak,  rapid  pulse,  slow  and 
shallow  respiration,  cold  skin,  covered  with  a  cold  sweat,  intense 
burning  heat  at  the  epigastrium,  /^zV^/with  burning  in  \ki%  fauces  and 
gullet,  and  exhaustive  purging ;  the  features  are  inore  or  less  retracted 
or  sunken  ;  these  symptoms  terminating  in  collapse  and  death,  or  slow 
convalescence  and  recovery  with  a  crippled  stomach. 

A  diagnosis  of  the  character  of  the  poison  swallowed  is  often 
afforded  by  the  stain  of  the  lips,  face  and  mucous  membrane,  to  wit: 
sulphuric  acid,  blackish  eschar  ;  nitric  acid,  yellowish  eschar  ;  caustic 


DISEASES   OF  THE  STOMACH.  61 

potash,  spreading  widely  and  softening  the  tissues  ;  corrosive  sublimate, 
whitish  or  glazed  ;  carbolic  acid,  white  and  corrugated. 

Prognosis.  Very  grave.  Many  perish  from  shock,  and  the  de- 
struction of  the  mucous  membrane,  which  prevents  nourishing.  Early 
treatment  when  no  perforation  of  the  walls  of  the  stomach  has  occurred 
and  recovery  is  possible,  the  organ  being  ever  after  much  weakened. 

Treatment.  At  once,  hypodermic  injection  of  morphina,  re- 
peated at  regular  intervals. 

Vomiting  should  be  encouraged  by  the  free  use  of  demulcetits. 

If  the  case  be  seen  within  a  short  period  of  the  swallowing  of  the 
poison,  the  proper  antidote  should  be  used  ;  but  if  some  hours  have 
elapsed,  it  is  useless.  Ice,  internally  and  externally,  gives  great  relief. 
The  stomach  should  be  washed  out  with  the  stomach  pump,  thereby 
removing  any  remaining  poison,  while  at  the  same  time  it  acts  as  a 
sedative  to  the  inflamed  membrane  ;  also  bismuthi subnit.,  grs.  xx-xxx 
every  hour  or  two,  is  beneficial. 

Milk  and  lime  water  is  the  only  food  that  should  be  given  by  the 
stomach,  enemata  being  used  to  support  the  system. 


CHRONIC  GASTRIC  CATARRH. 

Synonyms.  Chronic  gastritis ;  chronic  dyspepsia ;  drunkards' 
dyspepsia. 

Definition.  A  chronic  catarrhal  inflammation  of  the  stomach, 
with  thickening  of  the  coats  and  atrophy  of  the  gastric  glands ;  char- 
acterized by  tenderness  over  the  epigastrium,  impaired  appetite,  pain- 
ful and  imperfect  digestion,  thirst,  and  great  depression  of  spirits  or 
melancholia. 

Causes.  Repeated  attacks  of  acute  gastric  catarrh  ;  habitual  use 
of  spirituous  liquors ;  malaria  ;  disease  of  the  heart,  lungs,  pleura  or 
liver,  producing  chronic  congestion  of  the  stomachic  vessels  ;  cancer- 
ous or  other  degenerative  diseases  of  the  stomach. 

Pathological  Anatomy.  The  mucous  membrane  is  of  a  brown- 
ish or  slate  color,  elevated  into  ridges  from  hypertrophy,  the  result 
of  constant  congestion  ;  the  peptic  glands  first  increase  in  size, 
then  undergo  granular  change,  atrophy  of  their  cells  resulting. 
The  mucous  membrane  is  covered  with  a  thick,  alkaline,  tenacious 
mucus.  These  changes  may  affect  the  entire  organ  or  be  limited 
in  extent. 


62  PRACTICE   OF   MEDICINE. 

Symptoms.  Loss  of  appetite,  disagreeable  feeling  of  gnawing 
and  at  times  fullness  in  the  stomach,  tenderness  at  the  epigastrium, 
but  slightly  influenced  by  eating,  prominence  of  the  epigastrium,  from 
distention  by  decomposing  gases,  occasional  nausea  and  voifiitijig,  the 
latter  more  common  in  drunkards,  occurring  on  arising,  termed 
7norning  vomiting  and  consisting  of  glairy  mucus  raised  after  great 
retching ;  constant  thirst,  water  and  at  times  stimulus  being  craved  ; 
often  great  bunting  at  the  pit  of  the  stomach,  the  result  of  acidity  ; 
bowels  constipated,  urine  high  colored.  A  feeling  of  mental depressiojt 
and  sieepiessness,  with  occasional  attacks  of  vertigo,  add  to  the  misery 
of  the  patient.  Follicular  pharyngitis  of  an  aggravated  type  adds  to 
the  general  distress  of  the  patient.  The  imperfect  digestion  causes 
more  or  less  loss  of  flesh,  the  fat  disappearing,  the  muscles  relaxed 
and  the  skin  dry. 

Prognosis.  Favorable  as  to  life,  but  not  as  to  complete  recovery, 
the  atrophied  glands  more  or  less  hindering  digestion  and  assimilation. 

Treatraent.  Regulated  diet.  Avoid  fatty,  saccharine  and  starchy 
food.  A  milk  diet  is  beneficial,  to  which  may  be  added  beef  in  small 
amounts,  eggs,  oysters  and  a  few  fresh  green  vegetables.  Avoid  all 
tonics,  bitters,  or  acids,  unless  specially  indicated. 

Locally,  a  few  leeches,  dry  cups,  a  blister,  or  emplastrum  belladotince 
over  the  epigastrium. 

Purgatives  are  doubly  indicated  ;  first,  relieving  the  constipation  ; 
and  second,  clearing  the  stomach  of  the  tenacious  mucus,  which  neu- 
tralizes what  gastric  juice  is  secreted.  Appropriate  purgatives  are  the 
natural  mineral  waters,  such  as  Saratoga  or  Friedrichshall,  or — 

li .     Magnesii  sulph., .^i-ij 

Sodii  et  potass,  tart., S^M 

Acid,  tartaric, gr.  xx,  M. 

Dissolved  in  a  glass  of  water  and  drank,  effervescing,  an  hour  before 
breakfast. 

Digestion  may  be  temporarily  aided  by  pepsitium  or  lactopeptin 
with  the  meals. 

Great  relief  follows  the  systematic  drinking  of  one-half  to  one  pint 
of  hot  water  an  hour  before  meals. 

For  the  morbid  condition  itself  may  be  used,  liq.  potassii  arsenitis, 
g\X.\-\],  before  yneals,  or  bismuth  subnit.,  gr.  x-xx,  before  meals,  to 
which  may  be  added  sodii  bicarb.,  gr.  v  ;   or  argenti  nitrat.,  gr.  %-%  , 


DISEASES   OF   THE   STOMACH.  63 

OX  argenti  oxidum,  ^x.  j^-j,  in  pill,  before  meals,  or  acidum  hydro- 
chlorictcm  diliitiim,  in  water,  before  meals. 

Paiti  is  so  severe  in  some  cases  that  resort  must  be  had  at  times  to 
opium  or  belladonna  in  small  doses,  after  meals. 

Rest  of  the  body  is  almost  as  imperative  as  rest  of  the  stomach. 


GASTRIC    ULCER. 

Synonyms.     Chronic  gastric  ulcer  ;  perforating  ulcer. 

Definition.  A  solution  of  continuity,  involving  the  mucous  mem- 
brane and  one  or  more  layers  of  which  the  walls  of  the  stomach  are 
composed  ;  characterized  by  pain,  disorders  of  digestion  and  vomiting 
of  blood. 

Causes.  Anaemia  or  its  sequelae  the  chief  factor.  Most  common 
in  young  anaemic  women.  Virchow  claims  that  emboli  or  thrombi 
form  in  the  nutrient  gastric  arteries  which  have  lost  their  tonicity,  an 
ulcer  forming  at  the  point  of  obstruction. 

Pathological  Anatomy.  In  the  majority  of  cases  the  ulcer  is 
solitary.     The  posterior  wall  near  the  pylorus  is  the  most  common  site. 

In  a  typical  case  there  is  a  circular  hole,  with  sharp  borders  in  the 
serous  coat  of  the  stomach  ;  the  loss  of  substance  is  greater  in  the 
mucous  membrane  than  in  the  muscular  coat,  and  greater  in  this  than 
in  the  serous  coat,  so  that  the  ulcer  looks  like  a  shallow  funnel,  the 
apex  at  the  outer  wall,  the  base  at  the  inner  wall  of  the  stomach  ;  it 
is  first  round,  growing,  becomes  elliptical,  bulging  at  portions,  becom- 
ing irregular  ;  size,  from  X^K  inch  in  diameter.  When  the  ulcer 
heals  before  all  the  coats  are  perforated,  a  distinct  cicatrix  marks  the 
location.  During  its  progress  nutrient  vessels  are  eroded,  causing 
profuse  hemorrhage.  Chronic  gastric  catarrh  complicates  the  majority 
of  cases. 

Symptoms.  More  or  less  prominent  symptoms  of  indigestion. 
Pain  constant  at  the  "  pit  of  the  stomach,"  increased  by  taking  food, 
especially  of  an  irritant  kind,  the  pain  often  felt  in  the  back,  of  a 
burning,  gnawing  character.  Tenderness  at  one  or  more  points,  ex- 
tending from  the  front  to  the  back.  Vomititig  is  almost  as  constant  as 
pain,  coming  on  soon  after  eating  if  the  ulcer  is  at  the  cardiac  orifice, 
an  hour  or  so  after  if  it  is  at  or  near  the  pylorus.  Rejected  matter 
may  be  undigested  or  partly  digested  food,  or  simply  acrid  mucus. 


64  PRACTICE   OF   MEDICINE. 

Vofniiing  of  blood  in  large  quantities  and  arterial  in  color  is  almost 
diagnostic  of  gastric  ulcer  ;  the  blood  may  be  dark  in  color  if  it  has 
remained  in  the  stomach  some  time  before  being  rejected. 

Severe  and  frequent  attacks  of  gastralgia  may  add  to  the  suffering 
of  the  patient.  The  general  condition  of  the  patient  is  not  significant, 
some  being  greatly  debilitated,  while  in  others  the  nutrition  is  but 
little  deranged. 

Duration.  The  ulcer  is  slow  in  forming,  and  runs  a  very  chronic 
course,  an  average  duration  being,  perhaps,  a  year.  Cases  are  re- 
corded in  which  the  disease  has  suddenly  developed  and  terminated  by 
perforation,  perit07iiiis  and  death  within  two  weeks,  but  such  are  rare. 

DiagTiosis.  Duodenal  ulcer  presents  symptoms  so  akin  to  those 
of  gastric  ulcer  that  a  differential  diagnosis  is  impossible. 

Chronic  gastritis  \s  often  confounded  with  gastric  ulcer;  the  dis- 
tinctive points  are,  absence  of  vomiting  of  blood,  no  localized  con- 
stant pain  aggravated  by  food,  and  no  tenderness  in  the  back  ;  while 
the  symptoms  of  indigestion  are  marked  and  persistent,  with,  as  a 
rule,  a  history  of  spirit  drinking,  and  the  age  of  the  patient — middle 
life  ;  ulcer  in  the  young. 

The  points  of  distinction  between  ^<^^/rzV  cancer  2,Xi6L  gastralgia  vi\}i\. 
be  pointed  out  when  considering  those  affections. 

Prognosis.  Not  very  unfavorable.  Recoveries  are  frequent. 
The  dangers  2iXQ  perforation,  peritonitis  ox  fatal  hemorrhage . 

Treatment.  Give  the  stomach  as  complete  a  rest  as  possible ; 
this  is  accomplished  by  rectal  alimentation,  or  where  it  cannot  be 
carried  out,  exclusive  milk  diet,  adding  lime  water,  to  enable  the 
stomach  to  better  retain  the  milk  ;  the  amount  of  milk  should  be  one 
or  two  ounces  every  two  hours.  Rest  in  bed  is  paramount,  and 
should  be  insisted  upon. 

Y or  pain,  small  doses  of  morphina  should  be  used  as  needed. 

For  hemorrhage,  hypodermic  injections  o{  ergot  a  are  most  reliable. 
Plumbi  acetas,  gr.  j-iij,  arrests  the  bleeding  and  exercises  a  favorable 
influence  over  the  ulcer. 

For  the  ulcer,  lig.  potassii  arsenit.^  gtt.  j-ij  every  five  hours,  has 
given  excellent  results  in  several  cases  treated  by  the  author  ;  bismuthi 
sub?iitrat.,  gr.  xx-xxx,  combined  with  sodii bicarb.,  gr.  iij-v,  three  times 
a  day,  often  does  well;  arge?tti  nitras,  gr.  ^-j/^,  every  four  hours, 
or  argenti oxidum,  gr.  ss,  every  four  hours,  are  at  times  beneficial. 

\i perforation  and  peritonitis  result,  full  doses  of  opium  are  indicated. 


DISEASES   OF   THE   STOMACH.  65 

GASTRIC  CANCER. 

Synonyms.     Cancer  of  the  stomach ;  gastric  carcinoma. 

Definition.  A  peculiar  malignant  growth,  occurring  for  the  most 
part  at  the  pyloric  extremity  of  the  stomach,  making  constant  pro- 
gress, destroying  the  gastric  tissues  and  infecting  the  lymphatic  glands ; 
characterized  by  disorders  of  digestion,  pain,  vomiting,  marked  anae- 
mia, and  terminating  in  all  cases  by  the  death  of  the  patient. 

Cause.     Hereditary.    Develops  after  forty  years,  for  the  most  part. 

Pathological  Anatomy.  Cancer  of  the  stomach  is  the  most 
common  form  of  cancer.  It  is,  as  a  rule,  a  primary  cancer.  The 
variety  is  most  commonly  the  scirrhus,  next  in  frequency,  inechillary, 
the  least  frequent,  colloid.  As  regards  the  location,  eighty  per  cent. 
occur  at  the  pylorus. 

It  originates  usually  in  the  tubules,  rapidly  infiltrating  the  remain- 
ing tissues,  thickening  everywhere  as  it  progresses,  and  either  remains 
a  hard  nodulated  mass  or  undergoes  ulceration.  The  hard  nodulated 
growth  at  the  pylorus  constricts  the  orifice,  resulting  in  dilatation  of 
the  stomach.  The  lymphatic  glands  adjacent  to  the  stomach  are 
infiltrated,  secondary  cancers  resulting.  Ulceration  into  an  artery 
causes  hemorrhage  into  the  peritoneum,  resulting  in  local  peritonitis. 

Complications.     Fatty  heart ;  thrombosis  ;  tuberculosis. 

Symptoms.  The  development  of  gastric  cancer  is  insidious 
with  indigestio7i,  progressive  in  character,  associated  with  marked 
acidity,  Jlatulency  and  a  fetid  breath. 

The  majority  of  cases  have  vo7niting  immediately  after  eating,  if  at 
the  cardiac  orifice,  and  some  hours  after  it  at  the  pylorus ;  if  much 
dilatation  of  the  stomach  develop  the  vomiting  occurs  some  days  after 
eating.  The  rejected  matter  is  food  in  various  stages  of  digestion, 
associated  frequently  with  black  grunious  masses  of  altered  blood. 
Paitt,  marked  and  constant,  dull,  heavy,  increased  by  pressure, 
seldom  lancinating.  Marked  ancemia,  emaciation,  are  present,  the 
surface  having  an  earthy  or  fawn  color.  QEdema  of  the  ankles  is  an 
early  diagnostic  symptom  in  carcinoma  of  the  stomach,  often  occur- 
ring as  early  as  the  third  month.  A  tumor  is  found  in  three-fourths 
of  the  cases,  occupying  the  epigastric  region,  7tot  moviiig  with  in- 
spiration. 

The  duration  of  the  disease  is  about  one  year,  the  patient  dying 
from  exhaustion,  perito7iitis,  or  hemorrhage. 

Diagnosis.     The  continuous  presence  of  free  hydrochloric  acid 


66  PRACTICE   OF   MEDICINE. 

in  the  stomach  is  a  diagnostic  sign  of  great  value  in  excluding  the 
probable  existence  of  gastric  cancer.  Chronic  gastric  catarrh  differs 
from  gastric  cancer,  in  the  absence  of  a  tumor,  bloody  vomit,  charac- 
teristic pain,  peculiar  color  of  the  surface,  dropsy  and  the  rapid 
emaciation. 

Gastric  iilcer  differs  in  the  character  of  the  pain,  age  of  the  patient, 
large  amount  of  bloody  vomit,  absence  of  a  tumor  and  progressive 
emaciation.     Still  the  diagnosis  is  often  difficult. 

Abdominal  ticmors  may  raise  the  question  of  a  gastric  cancerous 
tumor ;  the  points  of  distinction  are  the  characteristic  symptoms  of 
gastric  cancer,  and  that  abdominal  tumors,  especially  of  the  liver  and 
spleen,  the  ones  most  apt  to  cause  error  in  diagnosis,  are  influenced 
by  inspiration,  while  tumors  of  the  stoinach  are  7iot  so  influenced. 

When  a  scirrhus  of  the  pylorus  lies  upon  the  aorta,  a  pulsation  may 
be  communicated  to  it,  raising  the  question  of  aneurism  of  the  abdomi- 
nal aorta,  but  the  expansile  pulsation  of  aneurism  (Corrigan's  sign) 
is  wanting,  as  are  the  other  symptoms  of  the  affection,  and  if  the 
patient  is  made  to  rest  upon  his  hands  and  feet,  the  stomachic  tumor 
falls  away  from  the  aorta  and  pulsation  ceases. 

Mikuliez  claims  that,  by  the  use  of  his  gastroscope,  regular  rhyth- 
mical motions  can  be  seen  when  the  pylorus  is  not  the  seat  of  cancer, 
and  that  such  movements  are  absent  when  it  is  the  seat  of  cancer. 

Prognosis.  Unfavorable.  Internal  medication  offers  no  hope, 
the  patient  usually  succumbing  from  starvation. 

Gastric  carcinoma  occurring  under  thirty  years  of  age  is  rapidly 
fatal,  not  conforming  to  the  usual  symptoms  as  seen  later  in  life ;  the 
characteristic  cachexia  is  commonly  absent  and  hasmatemesis  is  rare. 

Treatment.  We  possess  no  means  of  arresting  the  disease. 
"  Six  operations  have  been  practiced  for  the  relief  of  stenosis  of  the 
pylorus:  ist.  Pylorectomy ;  2d.  Gastro-enterostomy ;  3d.  Gastrectomy; 
4th.  Gastrostomy ;  5th.  Duodenostomy  ;  6th.  Digital  divulsion  of  the 
pylorus."  Professor  Billroth  has  excised  the  pylorus,  thereby  pro- 
longing life  ten  months. 

For  acidity  2cs\(S.  fetor  of  the  breath,  acidum  carbolicum,  gr.  }i-]/2,,  or 
carbo  animalis purificatus,  gr.  x-xxx,  affords  some  relief. 

For  vomitings  bismuth  and  opium,  or  the  washing  out  of  the  stomach 
with  the  stomach-pump. 

For  pain,  jnorphina. 

Avoid  stimulants. 


DISEASES   OF  THE   STOMACH.  67 

GASTRIC  DILATATION. 

Synonyms.     Pyloric  obstruction  ;  pyloric  stenosis. 

Definition.  An  abnormal  increase  of  the  cavity  of  the  stomach, 
with  the  walls  either  hypertrophied,  or  decreased  in  thickness  ;  char- 
acterized by  pronounced  indigestion,  vomiting  of  partly  digested  and 
partly  decomposed  food  at  intervals  of  a  day  or  two,  and  noisy  mov- 
ing of  flatus  in  the  abdomen  (borborygmus). 

Causes.  Most  common  cause  a  stricture  of  the  pylorus,  the 
result  of  cancer ;  pressure  of  tumor  against  the  pylorus,  preventing 
exit  of  stomachic  contents.  Loss  of  muscular  tone,  occurring  in 
anaemia.  Prof.  Bartholow  cites  cases  resulting  in  excessive  beer- 
drinkers,  who  drank  thirty  to  forty  glasses  of  beer  habitually,  every 
day. 

Pathological  Anatomy.  When  obstruction  exists  at  the  pylorus, 
the  whole  organ  is  dilated,  with  hypertrophy  of  the  muscular  layer  of  the 
stomach.  In  dilatation  without  pyloric  obstruction,  the  muscular  layer 
is  thinner  than  normal,  paler  in  color,  and  presents  signs  of  fatty  de- 
generation ;  the  mucous  membrane  is  also  pale,  thin,  and  without  rugse. 

Symptoms.  Those  of  the  disease  producing  the  obstruction  ^/2<;.? 
those  of  obstinate  chronic  gastric  catarrh,  with  characteristic  voniit- 
ijig :  the  cavity  having  a  greatly  increased  capacity,  large  accumula- 
tions take  place,  which  are  rejected  every  day  or  two,  partly  digested 
and  partly  decomposed.  Regurgitation  of  partly  digested  aliment, 
acrid,  acid  and  offensive,  is  very  common.  Bowels  constipated,  the 
stools  hard  and  dry. 

Physical  signs  of  gastric  dilatation  are  :  on  ijispection,  abnormal 
prominence  of  the  whole  epigastric  region,  with  a  tumor  in  \)!xq.  pyloric 
region  which  seems  to  be  connected  with  the  stomach  ;  percussiofi,  if 
empty,  tympanitic  note  extending  to  or  below  the  umbilicus,  having 
a  metallic  quality ;  if  the  stomach  be  filled,  high-pitched  flat  note  ; 
auscultation,  splashing  and  rumbling  sound,  the  succussion  sound 
being  distinct  if  the  body  be  shaken. 

Diagnosis.  Copious  vomiting  of  food  partly  digested,  once  in 
twenty-four  hours  or  less  often,  epigastric  distress  and  pain  resulting 
from  foul  smelling  and  acid  eructations  and  from  obstinate  constipa- 
tion. 

Penzoldt's  modification  of  Piorry's  method  of  determining  gastric 
dilatation  is  to  withdraw  the  contents  of  the  stomach  by  means  of  the 
oesophageal  tube  and  then  refilling  the  stomach  with  fluid.    By  noting 


B8  PRACTICE   OF   MEDICINE. 

the  lower  limit  of  percussion  dullness  thus  produced,  the  lower  border 
of  the  stomach  can  be  accurately  determined. 

Treatment.  Regulated  diet.  Restrict  the  use  of  fluids,  using  a 
"  dr)-  diet"  exclusively. 

If  the  result  of  pyloric  stenosis,  one  of  the  operations  mentioned 
for  pyloric  cancer  may  be  indicated. 

Regardless  of  the  cause,  washing  out  the  stomach  with  the  stomach 
pump,  every  day  or  two,  gives  relief,  and,  if  no  stricture  be  present, 
administer  strycJmina  or  7iux  vomica,  and  very  favorable  results  may 
follow. 


GASTRIC   HEMORRHAGE. 

Synonyms.     Haematemesis;  gastrorrhagia. 

Definition.  Gastric  hemorrhage  is  not,  strictly  speaking,  a  dis- 
ease, but  a  symptom ;  still,  vomiting  of  blood  occurs  under  such  a 
variety  of  conditions,  that  a  separate  consideration  is  desirable. 

Causes.  Ulcer  of  the  stomach  ;  cancer  of  the  stomach  ;  scurvy  ; 
purpura ;  hemorrhagic  malarial  fever ;  congestion  of  the  liver  or 
spleen  ;  vicarious  at  menstrual  period  ;  yellow  fever. 

Symptoms.  Added  to  the  symptoms  of  the  cause  of  the  hemor- 
rhage, are  difeelmg  offaintfiess  and  smkmg  at  the  pit  of  the  stomach, 
followed  by  the  ejection  of  blood  of  a  black,  grumous,  or  coffee-ground 
appearance.  Rarely,  and  then  generally  in  gastric  ulcer,  the  ejected 
blood  may  have  a  bright  red  appearance,  the  gastric  juice  not  having 
had  time  to  act  upon  it.  If  the  amount  of  blood  escaping  into  the 
stomach  is  large,  blood  will  be  voided  by  stool. 

Diagnosis.  Hemorrhage  from  the  liiftgsva^y  be  confounded  with 
gastric  hemorrhage.  In  the  former,  the  blood  is  red,  is  coughed  up, 
not  vomited,  and  is  associated  with  a  history  of  pulmonary  disease. 
The  chief  point  of  distinction  between  pulmonary  hemorrhage  and 
the  vomiting  of  red  blood  is,  that  in  the  former  you  can  discern  rales 
on  auscultating  the  chest,  and  they  are  absent  in  the  latter. 

Prognosis.  Depends  entirely  upon  the  cause,  the  most  unfavor- 
able being  the  resulCof  either  gastric  ulcer  or  cancer. 

Treatment.  Perfect  rest  in  bed.  Ice,  internally  and  applied  in 
bladders  over  the  epigastrium  and  along  the  spine. 

Hypodermic  injections  of  morphiiia  quiet  the  patient's  fear,  and  at 
the  same  time  have  a  constringing  effect  upon  the  vessels:     Extrac- 


DISEASES   OF  THE  STOMACH.  69 

turn  ergotcB  fluidutn  or  ergotin  hypodermically,  after  the  patient  is 
quieted,  or  liquor  ferri  siibsiclphatis,  gtt.  j-v,  well  diluted,  by  stomach. 

Cases  resulting  from  congestion  of  the  liver  or  spleen  are  benefited 
by  saline  purgatives. 

Allow  no  food  by  the  stomach  for  several  days,  nourishing  the 
patient  by  rectal  alimentation. 

The  hemorrhage  controlled,  the  future  treatment  is  guided  by  the 
exciting  cause. 

GASTRALGIA. 

Synonyras.  Cardialgia  ;  gastrodynia  ;  stomachic  colic  ;  spasm 
of  the  stomach  ;  neuralgia  of  the  stomach. 

Definition.  A  painful  condition  of  the  sensory  nerves  of  the 
stomach,  induced  by  various  sources  of  irritation  ;  characterized  by 
violent  paroxysms  of  gastric  pain  and  spasm,  associated  with  feeble 
cardiac  action,  and  symptoms  of  collapse. 

Causes.  The  affection  belongs  to  the  group  of  neuralgiae.  The 
most  important  factor  in  its  causation  is  a  general  nervous  depression  ; 
other  causes  are  malaria,  rheumatic  or  gouty  diathesis,  anaemia,  and 
certain  articles  of  diet. 

Symptoms.  Like  most  neuroses,  gastralgia  is  distinguished  by 
its  paroxysmal  character.     Romberg  thus  describes  an  attack  : — 

"  Suddenly,  or  after  a  feeling  of  pressure  at  the  prsecordium,  there 
is  severe  griping  pai?t  in  the  stomach,  usually  extending  to  the  back, 
with  a  feeling  of  faintness,  a  shrunken  countenance,  cold  hands  and 
feet,  and  an  itttermittent  pulse.  The  pahi  becomes  so  excessive  that 
the  patient  cries  out.  The  epigastrium  is  either  puffed  out,  like  a  ball, 
or  retracted,  with  tension  of  the  abdominal  walls.  There  is  oiten  pul- 
sation of  the  epigastrium.  External  pressure  is  well  borne,  and  not 
unfrequently  the  patient  presses  the  pit  of  the  stomach  against  some 
firm  substance,  or  compresses  it  with  his  hands.  Sympathetic  pains 
often  occur  in  the  thorax,  under  the  sternum,  and  in  the  oesophageal 
branches  of  the  pneumogastric,  while  they  are  rare  in  the  exterior  of 
the  body. 

"  The  attack  lasts  from  a  few  minutes  to  half  an  hour  or  longer  ;  then 
the  pain  gradually  subsides,  leaving  the  patient  much  exhausted  ;  or 
else  it  ceases  suddenly,  with  eructation  of  gas  or  watery  fluid,  or  with 
vomiting  and  with  a  gentle,  soft  perspiration,  or  with  the  passage  of 
reddish  urine." 


"70  PRACTICE   OF   MEDICINE. 

Besides  such  severe  attacks,  we  often  see  painful  sensations  in  the 
epigasirijnn,  of  various  degrees  of  intensity,  with  passing  faintness  or 
sinking  at  the  "pit  of  the  stomach." 

Diagnosis.  From  myalgia  of  the  abdominal  muscles,  by  the  pain 
of  gastralgia  being  more  acute  and  lancinating,  accompanied  by 
nausea  and  vomiting  and  the  absence  of  tenderness  on  pressure. 

From  intercostal  netcralgia,  by  the  fact  that  in  this  affection  the 
pain  is  in  the  left  hypochondrium,  with  painful  spots  along  the  course 
of  the  nerve  trunk  and  at  the  spine,  and  absence  of  nausea  and 
vomiting. 

From  gastric  cancer,  by  the  age,  character  of  the  vomited  matter, 
constancy  of  the  pain,  the  cachexia,  emaciation  and  the  tumor. 

From  gastric  ulcer,  by  the  localized  pain  and  its  constancy,  with 
tenderness  and  vomiting  of  blood,  and  constant  dyspeptic  symptoms, 
which  is  not  the  case  in  gastralgia. 

Prognosis.  As  to  perfect  recovery,  unfavorable,  but  not  danger- 
ous to  life.  A  chronic  affection,  in  that  attacks  are  prone  to 
return  from  time  to  time.  The  cause  has  much  to  influence  a  radical 
cure. 

Treatment.  For  the  paroxysi7i,  hypodermic  injections  of  mor- 
phina,  gr.  X2~i>  *^^  ^^  stomachic  administration  of  the  "  compound  of 
anodynes,"  the  so-called  chlorodyne,  in  doses  of  ttlx-xxx  p.  r,  n. 
The  relief  afforded  by  opium  in  some  form  is  so  decided  that  it  is 
prone  to  lead  to  the  opium  habit  when  the  attacks  are  frecjuent. 

In  the  interval,  regulated  diet  and  one  or  more  of  the  following 
remedies  :  quinina,  arsenicui7i,  bismuth,  ferrum,  liq.  iodi.  comp.,  or 
small  doses  oi potassiiiodidum. 

ATONIC  DYSPEPSIA. 

Synonyms.     Dyspepsia  ;  indigestion  ;  heartburn  ;  pyrosis. 

Definition.  A  functional  derangment  of  the  stomach,  with  either 
deficient  secretion  in  the  quantity  or  quality  of  the  gastric  juice ;  char- 
acterized by  disorders  of  the  functions  of  digestion  and  assimilation 
and  the  presence  of  sympathetic  nervous  symptoms. 

Causes.  Imperfect  mastication;  bolting  of  food;  eating  large 
quantities  of  food  ;  same  diet  long  continued  ;  depressed  nervous 
system,  from  worry  and  fatigue  ;  sedentary  habits  or  occupations.  It 
is  often  inherited. 


DISEASES   OF   THE   STOMACH.  71 

Symptoms.  Perverted  appetite,  capricious  or  lost ;  difficult  di- 
gestion, a  feeling  of  weight  or  fullness  in  the  epigastrium  ;  acidity 
from  the  decomposition  of  albuminoids;  heartburn,  flatidejicy,  regur- 
gitation, or  vo7niting  of  portions  of  partly  digested  food  or  acrid 
fluid — water-brash  or  pyrosis.  Pain  or  soreness  at  the  "  pit  of  sto- 
mach "  during  digestion.  Tongue  either  clean  or  broad,  flabby  and 
pale,  showing  marks  of  the  teeth.  Bowels  constipated  ;  iirine  gener- 
ally scanty  and  high-colored,  with  excess  of  urates  or  oxalates,  or,  in 
persons  of  nervous  type,  it  is  pale,  of  low  specific  gravity,  and  contains 
phosphates.  Drowsiness  after  meals,  with  wakefulness  at  night, 
defective  7nejnory,  headache  and  absent  mental  vigor,  vfiXh  flashes  of 
heat,  followed  by  more  or  less  perspiration.  Palpitation  of  the  heart 
with  irregularity  in  rhythm. 

Varieties  of  Dyspepsia. — I.  Nervous  dyspepsia,  atonic  form,  seen  in 
active  business  or  busy  professional  men,  especially  those  of  thin, 
spare  build,  of  nervous  temperament,  who  eat  meals  rapidly  and 
hurry  off  to  their  business.  These  cases  present  all  the  marked  ner- 
vous phenomena.  II.  Flatulent  dyspepsia,  seen  in  hysterical  indi- 
viduals, and  showing  immense  development  of  gas  throughout 
abdomen,  and  nervous  symptoms.  III.  Acid  dyspepsia,  water- 
brash.  Seen  when  the  diet  is  coarse.  Acidity  of  the  gastro-intestinal 
canal  and  of  the  urine.  IV.  Irritative  dyspepsia.  Vomiting  a 
prominent  symptom.  In  these  cases  the  tongue  is  small,  red  and 
pointed. 

Prognosis.  With  careful  living,  dyspepsia,  functional  in  charac- 
ter, is  curable.     It  has  been  aptly  termed  "  remorse  of  the  stomach." 

Treatm.ent  The  most  important  indication  is  to  regulate  the 
diet.  Forbid  saccharine,  starchy,  or  fatty  articles  of  food.  Eat  small 
amounts  at  a  time.  Perfect  insalivation  and  mastication.  Rest  after 
eating,  from  a  half  to  an  hour.  Allow  but  small  quantities  of  liquids 
with  the  meals.  In  the  vast  majority  of  C2iS&s  forbid  the  use  of  stimu- 
lants with  the  meals. 

Aid  digestio?i  with  pepsinum,  with  or  without  acidtun  hydrochlori- 
cum  dilutum. 

Stimulate  stomachic  peristalsis  with  mix  voinica,  gentian  or  cinchona. 

For  acidity,  alkalies,  at  time  of  acidity. 

For  flatulency ,  carbo  atiimalis  purificatiis,  gr.  x-xx,  or  one  or  more 
of  the  carminatives,  with  tinctura  7iucis  vomica  before  meals. 

Y ox  pyrosis,  bismuth  zjidpulvis  aroinaticus,  in  large  doses. 


PRACTICE   OF   MEDICINE. 


For  vomiting,  sodii  bromidimi  in  small  doses,  or  acidutn  carbolicum, 
gr.  \-\,  three  or  four  times  daily. 

For  consfipatiojt,  resifia  podophylhan,  at  bedtime. 
For  ancBmia,  massa  ferri  carbonatis  or  ferri  lactas. 


DISEASES   OF   THE    INTESTINAL    CANAL. 


INTESTINAL  INDIGESTION. 

Synonym.     Intestinal  dyspepsia. 

Definition.  A  derangement  in  the  functions  of  intestinal  diges- 
tion, resulting  in  the  more  or  less  complete  decomposition  of  the 
chyme,  from  defects  in  the  pancreatic,  biliary  or  intestinal  secretions, 
or  from  deficient  peristalsis,  one  or  more,  singly  or  combined  ;  char- 
acterized by  abdominal  pain,  distention,  tympanites  some  hours  after 
meals  and  nervous  perturbation,  anaemia  and  emaciation. 

Causes.  Imperfect  diet;  over  eating;  anaemia;  deficient  exercise ; 
worry  ;  immoderate  use  of  tobacco ;  diseases  of  the  intestinal  tract, 
liver  or  pancreas  ;  malaria.     Frequently  inherited. 

Symptoms.  Intestinal  indigestion  may  be  either  actcte  or  chronic, 
the  latter  the  more  common. 

Acute  variety,  the  result  of  an  irritant  in  the  duodenum  ;  rapidly 
developed  paiii,  flatulency,  borborygmi,  slight  feverishness,  coated 
tongue,  loss  of  appetite,  headache,  pains  ifi  the  limbs,  usually  termi- 
nating in  a  mild  attack  of  diarrhcea. 

If  the  attack  develops  rapidly,  the  sudden  formation  of  gases 
results  in  a  paroxysm  of  colic. 

Severe  attacks  are  associated  with  disordered  hepatic  function,  to 
wit:  light-colored  stools,  slight  jaundice  and  high-colored  urine. 

Chronic  variety,  resulting  from  a  greater  or  less  decomposition  of 
the  partly  altered  food  from  the  stomach.  Pain,  varying  in  char- 
acter, occurring  from  two  to  four  or  six  hours  after  meals,  with  slight 
tenderness  and  some  fiilhiess  in  the  right  hypochondrium,  epigas- 
trium or  the  umbilical  region.  Tyinpanites  and  borborygmi  are 
marked,  the  result  of  gaseous    accumulations  which    have  resulted 


DISEASES   OF    THE    INTESTINAL   CANAL.  73 

from  the  decomposition  of  the  intestinal  contents.  Dyspncea,  the  re- 
sult of  pressure  against  the  diaphragm,  is  of  frequent  occurrence. 
Marked  nervous  phenomena  develop,  the  result  of  the  ansemia  from 
deficient  assimilation  and  from  the  depressing  influence  on  the  ner- 
vous system  of  the  absorption  of  the  "gases  of  decomposition  ;"  de- 
pression of  spirits,  hypochondriasis ,  sleeplessness,  disturbi)ig  dreams, 
headache,  vertigo,  buzzing  in  the  ears,  musca  volitantes,  deficient 
mental  application,  cardiac  irritability,  numbness  and  tingling  in  the 
extremities,  anomalous  pains  throughout  the  body,  and  in  marked 
cases,  attacks  oi fainting,  epileptifori7i  and  cataleptic  attacks. 

The  skin  is  harsh  and  dry,  the  bowels  are  sluggish  or  constipated, 
the  urine  is  high  colored,  of  increased  density,  decidedly  acid,  and 
on  coohng  deposits  lithates,  uric  acid  and  oxalate  of  lime  crystals. 

Functional  derangement  of  the  liver  follows  after  a  time,  adding  to 
the  general  distress. 

AncB7nia  and  e?naciation  result  if  the  attack  be  protracted. 

Diagnosis.  With  our  present  knowledge  it  is  usually  impossible 
to  designate  forms  of  intestinal  indigestion  due  to  defects  in  the 
quantity  or  quality  of  either  the  pancreatic,  biliary  or  intestinal 
secretions. 

Acute  intestinal  indigestioji  differs  from  gastric  indigestion  in  the 
time  of  development  of  the  various  phenomena,  in  the  latter  the 
symptoms  appearing  almost  immediately  after  meals,  while  in  the 
former  not  appearing  until  two,  four  or  six  hours  after. 

Chronic  intestinal  indigestion  may  mislead  the  physician  if  the 
various  nervous  phenomena  are  of  a  marked  character,  and  a  careful 
history  of  the  case  is  not  developed. 

Prognosis.  Favorable  if  proper  and  early  treatment  is  inaugu- 
rated, unless  the  result  of  an  organic  lesion. 

Treatment.  Acute  variety,  the  result  of  indigested  food,  is  best 
treated  by  opium  in  some  form,  to  relieve  the  acute  suffering,  warmth 
to  the  abdomen,  and  a  prompt  cathartic  to  cause  its  rapid  expulsion. 

Chronic  variety.  Of  the  first  importance  is  the  diet,  which  should 
be  restricted  in  amount  and  confined  almost  entirely  to  such  articles 
as  are  readily  digested  in  the  stomach,  such  as  beef,  eggs  and  milk. 

The  hepatic,  pancreatic  and  intestinal  secretions  should  be  stimu- 
lated by  a  course  of  alkalies,  one  of  the  most  efficient  being  sodiiphos- 
phas,  5j-ij,  three  times  a  day. 

Aid  intestinal  digestion  by  the  administration  of  the  liquor  pa7icre- 
6 


74  PRACTICE   OF   MEDICINE. 

aticus,  fo J~^'^''  of  ^'^^  extractum  pancreatis,  gr.  ij-vj,  with  sodii  bicar- 
bonatis,  gr.  v-x,  two  or  three  hours  after  meals. 

For  constipation,  bitter  waters,  such  as  Friedrichshall,  Pullna,  or 
Hunyadi  Janos,  or  resma  podop]iylluin,  at  bedtime. 


INTESTINAL    COLIC. 

Synonyms.     Enteralgia  ;  tormina  ;  gripes. 

Definition.  A  spasmodic  contraction  of  the  muscular  layer  of 
the  intestinal  tube ;  characterized  by  acute  paroxysmal  pain  near  the 
umbilicus,  relieved  by  pressure,  and  associated  with  feeble  cardiac 
action. 

Causes.  Constipation  ;  presence  of  indigestible  food  ;  collections 
of  flatus;  an  abnormal  amount  of  bile  discharged  into  the  intestines; 
lead  poisoning  ;  syphilis  ;  chronic  malaria  ;  rheumatism  ;  hysteria. 

Symptoms.  Ro)nberg  \}[\Vi's  describes  a  paroxysm:  "There  are 
attacks  of  pain,  spreading  from  the  navel  over  the  abdomen,  alter- 
nating with  intervals  of  ease.  The  pain  is  fearing,  C7ctting,  pressi?tg, 
most  frequently  twitching,  pine hi7ig,  accompanied  by  peculiar  bear- 
ing-down pains.  The  patient  is  restless,  and  seeks  relief  \n  changing 
his  position  and  in  compressing  the  abdomen  ;  his  surface  may  be  cold 
and  his  features  pinched.  The  pulse  is  small  and  hard.  The  abdo- 
men is  tense,  whether  puffed  up  or  drawn  inward.  There  are  often 
nausea  and  vomiting,  and  desire  for  stool.  There  is  usually  constipa- 
tion, but  sometimes  the  bowels  are  regular  or  even  too  loose.  Dura- 
tion from  a  few  minutes  to  several  hours,  relaxing  at  intervals.  The 
attack  ceases  suddenly,  with  a  feeling  of  the  greatest  relief,  although 
some  soreness  remains  for  a  few  days." 

Lead  colic  is  always  preceded  by  symptoms  of  lead  poisoning,  to 
wit:  slate-colored  skin,  dark  gums,  showing  blue  line,  heavy  breath, 
with  sweetish  metallic  taste,  obstinate  constipation,  impaired  appetite, 
slow  pulse  and  contracted  abdominal  walls. 

Diagnosis.  Gastralgia  differs  from  colic,  in  the  pain  being  in  the 
epigastric  region  and  associated  with  disorders  of  digestion. 

In  hepatic  colic,  or  the  passage  of  gall  stones,  the  pain  is  in  the 
hepatic  region,  attended  with  soreness  over  the  gall  bladder,  and 
retching  and  vomiting,  followed  by  jaundice  and  the  presence  of  bile 
in  the  urine. 

In  nephritic  colic  the  pain  follows  the  course  of  one  or  both  ureters, 


DISEASES   OF   THE   INTESTINAL  CANAL.  75 

shooting  to  loins  and  thigh,  with  retraction  of  the  testicle  of  the  affected 
side,  strangury  and  bloody  urine. 

In  uterine  colic  the  pain  is  in  the  pelvis,  and  associated  with  men- 
strual disorders,  in  fact,  a  dysmenorrhoea. 

In  ovarian  colic  or  neuralgia,  pain  on  pressure  over  the  ovaries, 
with  hysterical  phenomena. 

Inflammatory  disorders  of  the  abdonieji  differ  from  colic  by  the 
presence  of  fever  and  tenderness  on  pressure. 

Prognosis.  Most  favorable.  Death  is  the  rarest  termination 
possible. 

Treatment.  Relief  of  pain  is  the  first  indication,  and  is  best 
accomplished  by  a  hypodermic  injection  of  viorphifia,  gr.  ye-yi, 
which  has  the  additional  advantage  of  relaxing  the  spasm,  thereby 
favoring  the  action  oi  purgatives,  which  should  soon  follow.  One  of 
the  best  in  colic,  no  matter  from  what  cause,  is  masses  hydrargy- 
rum, gr.  v-x,  or  hydrargy?'i  chloridiim  mite,  gr.  Yz  every  half  hour 
until  four  or  five  grains  are  taken,  followed  by  a  mild  saline 
cathartic. 

After  the  relief  of  the  pain  and  free  action  of  the  bowels,  the  cause 
of  the  attack  should  be  ascertained  and  corrected,  to  prevent  future 
suffering. 

For  lead  colic,  morphina,  for  the  pain  ;  oleum  rici7ii  or  magnesii 
sulphas,  ^j,  every  hour  for  the  constipation,  and  potassii  iodidum 
gr,  v-x,  after  meals,  to  eliminate  the  metal  from  the  system. 


CONSTIPATION. 

Synon37ms.     Intestinal  torpor  ;  costiveness. 

Definition.  A  functional  inactivity  of  the  intestinal  canal,  either 
due  to  atony  of  the  muscular  coat,  causing  lessened  peristalsis,  or  to 
a  deficiency  of  intestinal  and  biliary  secretion  ;  characterized  by  a 
change  in  the  character,  frequency  and  quantity  of  the  stools. 

Causes.  Dyspepsia  ;  character  of  the  food  ;  habits  of  the  patient ; 
diseases  of  the  stomach  and  liver  ;  malaria  ;  lead  poisoning  ;  syphilis. 

Symptoms.  In  the  normal  condition  the  majority  of  persons 
have  one  stool  each  day,  although  it  is  not  to  be  considered  abnormal 
if  more  or  less  than  that  number  occur. 

The  bowels  are  moved  every  three  ox  four  days,  with  great  straitiing 
and  distress,  the  face  often  fli^shed,  the  cerebral  vessels  full. 


n 


PRACTICE   OF   MEDICINE. 


Or  in  other  cases  the  bowels  may  be  relieved  once  a  day,  but  the 
stoolis  small a7id hard,  causing  great  pain. 

Another  group  of  cases  \i-^\Q.  frequent  stools  during  the  day,  small 
and  non-for?ned,  due  to  retained  hardened  feces  acting  as  an  irritant 
upon  the  rectum. 

The  change  in  the  character  of  the  stools  is  soon  followed  by 
symptoms  of  dyspepsia,  headache,  mental  torpor,  vertigo,  palpi- 
tation on  exertion,  and  in  many  cases  with  great  distention  of  the 
abdomen. 

Prognosis.     Death  never  results  from  functional  constipation. 

Treatment.  The  successful  treatment  depends  upon  the  removal 
of  the  cause  and  the  hearty  co-operatio7i  of  the  patient. 

First,  the  patient  must  have  a  regular  hour  each  day  for  goifig  to 
stool,  and  must  remaifi  a  sufficie?tt  tijne  to  permit  a  thorough  evacua- 
tion of  the  bowels. 

Second,  the  diet  must  be  carefully  regulated. 

Third,  purgative  mineral  waters  or  cathartic  medicines  are  to  be 
used  with  caution,  their  reckless  administration  often  doing  more 
harm  than  good. 

Fourth,  either  of  the  following  formulae,  aided  by  the  enforcement 
of  the  above  rules,  will  give  good  results  : — 

B  .     Ext.  nucis  vomicse, gr*  X 

Ext.  belladonnae  alco., gf-  X 

Extract  aloes  aqua, gr.  ss 

Pulv.  rhei, gr.  j 

Olei  cajuputi, gtt.  j.  M. 

In  pill,  at  bedtime,  and  after  a  week,  every  second  or  third  night. 

R .     Resinoe  podophyl., 

Ext.  physostig., 

Ext.  belladonnae  alco., 

Aloine, aa gr.  X- 

In  pill,  every  night,  or  second  or  third  night. 

R;.     Ext.  cascarse  sagradoe  fld., n\^xxx 

Glycerini, .    .    .  rT\,x 

Syr.  sarsaparilkc, n\^xx. 

Hour  after  meals,  or  once  a  day,  as  indicated. 

Success  often  follows  an  enema  oi glycerini  3j-iv,  or  a  suppository 
oi  glycerinum. 

Electricity  to  the  abdomen  is  worthy  a  trial ;  one  pole  over  ab- 
domen the  other  at  anus  ;  using  either  galvanism  or  faradism. 


DISEASES   OF   THE    INTESTINAL  CANAL.  77 

DIARRHCEA. 

Synonyms.     Enterorrhoea  ;  alvine  flux  ;  purging. 

Definition.  Frequent  loose  alvine  evacuations,  without  tenes- 
mus ;  due  to  functional  or  organic  derangement  of  the  small  intes- 
tines, produced  by  causes  acting  either  locally  or  constitutionally. 

Causes.  Those  acting  locally,  such  as  indigestiofi,  indigestible 
food,  impure  food  and  water,  irritating  matters  or  secretions  poured 
into  the  bowels,  or  entozoa,  cause  the  flux  by  a  direct  irritation  of  the 
mucous  surface. 

Attacks  of  diarrhoea  due  to  constitutional  derangement  may  be 
secondary  to  such  diseases  as  tuberculosis,  pycemia,  albuminuria, 
typhoid  fever,  or  disturbances  of  the  functions  of  other  organs,  giving 
rise  to  vicarious  fluxes. 

Atmospheric  changes  as  well  as  a  sudden  mental  shock  will  predis- 
pose to  an  attack  of  diarrhoea. 

Forms.     Acute  and  chronic. 

Symptoms,  Acute  diarrhoea  presents  itself  in  several  varieties, 
the  result  of  its  particular  cause,  to  wit : — 

Fectilent  diarrhcea.  A  few  hours  after  meals  the  patient  feels  colicky 
pains  atid  flatulency ,  with  a  desire  for  stool.  There  is  often  nausea, 
coated  tongue,  but  seldom  vomiting.  The  pain  is  generally  relieved 
by  the  purging  which  ensues.  The  stools  have  a  feculejit  character, 
are  of  brown  fluid,  containing  fseces,  often  offensive,  the  color 
becoming  lighter  after  four  or  five  evacuations.  Constitutional  symp- 
toms are  wanting. 

This  form  is  the  result  of  over  eating,  eating  too  rapidly,  or  indi- 
gestion of  different  forms,  or  worms  in  the  intestinal  canal,  and 
patients  generally  recover  in  a  day  or  two. 

Lienteric  diarrhcea.  In  this  form  there  is,  with  the  frequency  of 
evacuations,  a  wa^it  of  assimilation  oi  food,  which  passes  through  the 
intestines  more  or  less  unaltered.  The  stools  are  frequent,  mucous 
or  serous,  more  or  less  covered  with  bile,  mixed  with  U7idigested  food. 
In  this  form  the  patients  emaciate  rapidly,  owing  to  the  deficient 
assimilation,  the  digested  portions  of  the  food  being  hurried  on  by  the 
increased  peristalsis  of  the  irritated  bowel.  It  is  usually  subacute  in 
its  course. 

Bilious  diarrhoea.  The  stools  are  frequent,  green  or  yellow,  with 
scaldi7ig  sensations  at  the  anus  and  gripifig  pains  in  the  abdomen. 
Excessive  biliary  secretion  is  the  irritating  cause. 


7-8 


PRACTICE   OF   MEDICINE. 


Any  of  the  above  forms  may  pass  into  chronic  diarrhoea  by  excit- 
ing permanent  diseases  of  the  intestines.  Diarrhoea  due  to  constitu- 
tional causes  will  be  mentioned  when  speaking  of  those  conditions. 

Chronic  diarrhoea  results  from  repeated  attacks  of  the  acute  form, 
or  is  the  result  of  some  cachexia.  The  symptoms,  as  far  as  the  stools 
are  concerned,  are  much  the  same  as  the  acute  disease,  except  they 
are  paler,  whence  it  has  been  termed  white  flux  ;  in  addition,  dyspep- 
tic symptoms,  aphthous  condition  of  the  mouth  and  \.ov\g\iQ,/laticlency , 
colic,  emaciation  and  ance7nia.  The  appetite  is  at  times  capricious, 
again  impaired. 

Prognosis.  Favorable  \n  feculent  and  bilious  forms  ;  unfavorable 
in  lienteric  and  chronic  forms  when  emaciation  begins.  Diarrhoea 
occurring  as  a  symptom,  the  prognosis  is  controlled  by  the  original 
disease. 

Treatment.  Acute  diarrhoea.  If  caused  by  indigestion  the  indi- 
cation is  for  a  laxative  ;  for  adults,  tinct.  rhei.  or  ol.  ricini,  or  both  ; 
for  children  between  one  and  two  years  of  age — 


1 


K  .     Pulv.  ipecac, gr. 

Pulv.  rhei, gr.  X~/^ 

Sodii  bicarb., gr.  ss-ij. 

Every  four  hours  until  the  character  of  the  stools  change. 


M. 


After  the  irritant  is  removed,  for  an  adult,  opium  in  some  form, 
combined  with  kino  or  tannin ;  or  the  following  modification  of 
"  Squibb's  diarrhoea  mixture  :  " — 


R .     Tinct.  opii  deodorat., 
Tinct.  camphorge,    . 
Tinct.  capsici,  .    .    . 
Chloroformi  purse,  . 
Spts.  villi  gallici, 

Alcoholis, ad 

SiG. — One  teaspoonful,  \^.  r.  n. 


f  2  viss 

f  3;  iiss 
f  31V. 


M. 


For  children — 


R .     Bismuth, gr.  iij-v. 

Cretce  prsep., gr.  v. 

Every  two  hours. 


M. 


In  adults,  an  opium  suppository  often  checks  a  flux  that  is  unin- 
fluenced by  opium  internally. 


DISEASES   OF   THE    INTESTINAL   CANAL.  79 

For  the  bilious  form — 

R  .     Hydrargyri  chlor.  mitis, gi"-  /^ 

Sodii  bicarb., gi"-  ij 

Pulv.  opii, gi".  >(•  M. 

In  powder,  every  two  or  three  hours,  until  eight  powders  are  used,  fol- 
lowed by  large  doses  of  bismuth  and  pepsinum. 

In  all  acute  forms  restricted  and  regulated  diet  are  imperative,  pure 
milk  with  liquor  calcis  being  the  most  suitable. 

Chronic  diarrhcea.  Bismuth,  gr.  xxx-xl,  in  milk,  every  four  hours  ; 
Hope'' s  cajnphor  mixture,  every  four  hours ;  cupri  sulphas,  gr.  -J^-, 
ext.  opii,  gr.  y^,  every  four  hours ;  argenti  nitras,  gr.  Yz,  ext.  opii,  gr. 
\,  every  five  hours ;  may  all  be  used  with  more  or  less  success  ;  when 
dry  tongue  2indi  great  flatulency,  use — 

^.     01.  terebinthini, , f^j 

01.  amygdal,  express,, f^ss 

Tinct.  opii, f.^ij 

Mucil.  acacise f,::^v 

Aq.  lauro-cerasi, f^ss.  M. 

SiG. — f 5J  every  three  or  four  hours. 

The  diet  should  be  nutritious  in  character,  and  moderate  stimulants 
are  indicated.    Activity  of  the  skin  and  kidneys  should  be  encouraged. 


CATARRHAL  ENTERITIS. 

Synonyms.  Ileo-colitis ;  acute  diarrhcea ;  inflammation  of  the 
bowels. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  small  intestines;  characterized  by  fever,  pain,  tenderness  and 
looseness  of  the  bowels.  When  the  catarrh  is  limited  to  the  duode- 
num, it  is  termed  dzwdenitis. 

Pathological  Anatomy.  There  first  ensues  hypercemia  of  the 
mucous  membrane  and  intestinal  glands,  manifested  by  redness, 
swelling  and  cedema  ;  this  is  followed  by  increased  secretio7i  and  an 
overgrowth  and  desquamation  of  the  epithelium,  together  with  a  copi- 
ous ^^«(?nz//^«  of  young  cells.  As  a  result  of  the  hyperaemia,  rupture 
of  the  capillaries  and  extravasation  of  blood  often  occur. 

The  swollen  glands  show  a  strong  tendency  to  ulcerate.  This 
catarrhal  process  may  involve  the  whole  tube  or  be  limited  to  portions 
of  it 


80  PRACTICE   OF   MEDICINE. 

Causes.  Improper  and  indigestible  food ;  summer  temperature 
and  exposure  to  cold  and  wet  while  perspiring. 

Symptoms.  Begins  with  languor,  followed  by  chillijiess  and 
fever,  the  temperature  ranging  at  io2°-io3°,  this  is  followed  hy  pain, 
colicky  and  paroxysmal  in  character,  situated  above  the  umbilicus, 
localized  te7iderness  and  loose  evacuatio7ts.  Nausea  and  vomitinsr 
often  occur.  The  stools  contain  but  little  fecal  matter,  are  yellow  or 
greenish-yellow  in  color,  mixed  with  undigested  food  ;  if  the  stools  are 
numerous,  they  become  whitish  and  watery,  the  so-called  '^rice- 
water"'  discharges.  The  appetite  is  impaired,  and  this,  with  the  want 
of  assimilation  and  great  waste,  soon  produce  extreme  weakness  and 
emaciation,  which  is  always  more  marked  in  children. 

Duration.  In  mild  cases,  four  or  five  days  ;  severe  cases  continue 
more  or  less  marked  for  a  w-eek  or  two. 

Diagnosis.  From  colic,  by  the  absence  of  tenderness  and  fever, 
and  presence  of  constipation  and  its  paroxysmal  character. 

From  typhoid  fever,  by  the  absence  of  prodromes,  characteristic 
temperature  record  and  eruption. 

For  points  of  distinction  from  dysentery  or  peritonitis ,  see  those 
affections. 

Prognosis.  Favorable,  if  early  and  proper  treatment  is  ob- 
served. 

Treatment.  Rest  the  bowels  by  a  restricted  diet,-  such  as  milk 
and  lime  water,  or  weak  mutton  or  chicken  soups,  with  well  boiled 
rice  added. 

Keep  the  patient  quiet  in  bed,  a  difficult  matter  in  the  case  of 
children. 

For  adults,  opium  is  the  remedy,  in  doses  to  control  the  symptoms ; 
mild  cases  do  well  with — 

R.     Ext.opii, gr.  %-y2 

Camphoroe, gr.  iij.  M. 

In  pill,  every  three  hours. 

Or— 

R .     Tinct.  opii  deodorat., gtt.  x 

Liq.  potassii  cilrat.. ^ij.  M, 

Every  four  hours. 

The  strength  and  the  frequency  of  administration  of  either  of  these 
formulae  must  be  governed  by  the  severity  of  the  attack. 


DISEASES   OF   THE    INTESTINAL  CANAL.  81 

For  children — 

5t .     Tinct.  opii  deodorat., gtt.  j 

Bismuth  subnit., gr.  v 

Mist,  cretse, f^j.  M. 

Every  four  hours,  for  a  child  of  one  year. 

If  the  case  shows  the  least  tendency  to  linger,  the  acid  treatment 
should  be  substituted  for  the  above,  the  best  of  which  is  "  Hope's 
Camphor  Mixture,"  the  formula  being — 

R  .     Acidi  nitrosi, f  5  j 

Tinct.  opii, gtt.  xl 

Aquae  camphorae, f^^viij.  M. 

The  dose  ranging  from  i'^\  to  f  ^  ij,  according  to  the  age. 

Acidum  sulphuricimi  dilutuni  may  be  substituted  for  the  acidum 
nitrosum  in  the  above  formula. 

Locally,  poultices,  warm  fomentations,  or  tuig.  belladonn(E  or 
oleum  camphoratce,  give  great  relief. 

CROUPOUS  ENTERITIS. 

Synonym.     Membranous  enteritis. 

Definition.  A  croupous  inflammation  of  the  mucous  membrane 
of  the  small  intestines  ;  characterized  by  tenderness,  paroxysmal  pain, 
moderate  fever,  and  the  formation  and  discharge  of  membranous 
shreds  or  casts. 

Causes.  A  disease  of  adult  life.  The  female  sex  more  liable 
than  the  male,  and  neuralgic,  nervous,  hysterical  or  hypochondriacal 
subjects  are  more  subject  to  it  than  are  other  types. 

A  peculiar  state  of  the  nervous  system  seems  necessary  to  its  pro- 
duction. 

Pathological  Anatomy.  A  subacute  inflammation  of  the  small 
intestines,  during  which  the  mucous  membrane  becomes  covered  with 
a  whitish  or  grayish-white,  firmly  adherent,  membranous  deposit, 
cemented  together  by  a  coagulable  exudation,  and  prolonged  by- 
rootlets  from  its  under  surface  into  the  intestinal  follicles. 

Symptoms.  Begins  by  feverishness,  feeling  of  soreness  and  dis- 
tention of  the  abdomen  ;  these  are  followed  by  pains  of  a  colicky 
character,  severe  and  depressing,  felt  around  the  tnnbilictis,  continuing 
for  half  an  hour,  an  hour  or  longer,  and  after  a  longer  or  shorter  inter- 
val occurring  again  ;  these  phenomena  continue  for  a  day  or  two,  when 
7 


82  PRACTICE   OF   MEDICINE. 

looseness  of  the  bowels,  with  distressing /^z;z  and  tenesmus  occur,  the 
stools  containing  ynucus,  with  or  without  blood,  and  shreds  of  ineinbrane 
or  cylindrical  casts  of  the  bowel.  Great  relief  is  then  experienced, 
although  2.  feeling  of  rawness  or  soreness  persists  for  a  day  or  two 

Preceding  the  local  manifestations  of  the  disease  are  attacks  of 
hysteria,  hypochondriasis,  neuralgia,  nervousness  or  excitability. 

The  paroxysms  recur  at  intervals  of  a  week  or  two,  or  after  several 
months ;  as  long  an  interval  as  three  years  between  attacks  is 
recorded. 

Diagnosis.  Peritonitis  may  be  suspected  until  the  characteristic 
stools  occur. 

Dysentery  is  excluded  when  the  shreds  and  casts  of  membrane 
appear. 

Prognosis.  Favorable  as  to  life,  but  one  of  the  most  difficult  of 
diseases  to  eradicate. 

Treatment.  The  diet  must  be  such  as  contains  but  a  minimum 
of  fecal-forming  matter. 

For  the  pain  and  stifferi7ig,  opium  in  some  form  is  indicated,  the 
most  effective  being  a  hypodermic  injection  of  morphina. 

For  constipation  during  a  paroxysm,  an  emulsion  of  oleum  ricini 
and  terebinthina  is  of  benefit.  To  prevent  a  return  of  the  paroxysms 
either  lig.  potassii  arsenitis,  gtt.  j-ij,  before  meals,  or  hydrargyri 
chloriduni  corrosivum,  gr.  -^j^,  three  times  a  day,  with  a  course  of 
oleum  moT^huae,  seems  to  answer  in  the  majority  of  cases.  Prof.  Da 
Costa  speaks  highly  of  pix  liquida  in  some  form,  as  an  alterative  to 
the  mucous  membrane. 

Under  no  circumstances  must  the  bowels  become  constipated. 


CHOLERA  MORBUS. 

Synonyms.     Sporadic  cholera  ;  English  cholera  ;  bilious  cholera. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  oi sudden  onset;  character- 
ized by  violent  abdominal  pains,  incessant  vomiting  and  purging, 
cold  surface,  rapid,  feeble  pulse,  spasmodic  contractions  of  the  mus- 
cles ot  the  abdomen  and  extremities,  and  prostration. 

Causes.  A  disease  of  summer  and  early  autumn,  climatic  influ- 
ence being  an  important  factor.  Irritants  of  all  kinds,  unripe  fruits 
and  vegetables,  and  fermentation  of  food. 


DISEASES   OF   THE   INTESTINAL  CANAL.  83 

Patholo^cal  Anatomy.  Cases  in  which  death  has  occurred 
within  a  few  hours  present  no  pathological  changes. 

Generally,  however,  the  gastro-intestinal  mucous  membrane  is  con- 
gested and  denuded  of  epithelium ;  the  Solitary  and  Peyerian  glands 
are  swollen  and  prominent.  The  blood  is  thick,  and  dark  in  color ; 
the  kidneys  are  enlarged  and  congested ;  and  in  prolonged  cases 
there  are  appearances  of  granular  changes  in  the  muscular  system. 

Symptoms.  Onset  sudden  and  violent,  and,  unfortunately,  gen- 
erally after  midnight,  with  chilliness,  intense  nausea,  vomiting  and 
purging,  accompanied  with  distressing  burning  or  tearing  abdominal 
pains  or  colic.  The  vomited  matter  at  first  consists  of  the  ordinary 
contents  of  the  stomach,  and  the  stools  of  ordinary  faeces,  but  soon 
the  discharges  by  vomit  and  stool  are  liquid^  whitish  or  of  a  green  or 
yellowish  tint ;  if  the  attack  is  severe  or  protracted  the  discharges 
partake  of  the  "rice-water'''  character.  The  patient  is  rapidly  ^w«- 
ciated  and  reduced  in  strength,  the  body  shrinks,  the  surface  cold  and 
covered  with  a  clammy  sweat,  and  the  pulse  feeble.  Intense  thirst  is 
present,  and  when  drink  is  given  it  is  at  once  rejected. 

Aggravating  the  distress  of  the  patient  are  severe  cramps  of  the 
muscles,  and  especially  those  of  the  calves,  and  of  the  flexors  of  the 
thighs,  forearms,  fingers  and  toes. 

Termination.  Mild  cases  often  terminate  favorably  without 
treatment,  the  patient  able  to  be  around  in  a  day  or  two,  although 
weak. 

Severe  cases,  the  vomiting  and  purging  cease  after  some  hours,  but 
the  patient  remains  weak,  with  an  irritable  stomach  and  bowels  for  a 
week  or  two. 

Grave  cases,  the  true  cholera  type,  recover  from  the  prostration 
very  gradually ;  reaction  coming  on  slowly  and  usually  passes  into  a 
typhoid  condition  of  some  weeks'  duration. 

Diagnosis.  Asiatic  cholera  and  cholera  morbus  are  easily  con- 
founded during  an  epidemic  of  the  former,  and  there  are  no  positive 
points  of  discrimination,  unless  the  comma  bacilli  oi  Koch  are  proven 
to  be  always  in  the  true  cholera  stools. 

Irritant  poisons,  such  as  tartar  emetic,  elaterium,  or  other  sub- 
stances, cause  vomiting  and  purging,  similar  to  cholera  morbus,  and 
are  only  discriminated  from  it  by  the  history. 

Prognosis.  In  the  majority  of  cases  favorable.  The  mortality 
is  about  five  per  cent. 


84  PRACTICE   OF   MEDICINE. 

Treatment.  At  once,  regardless  of  the  cause,  a  hypodermic 
injection  of  morphines  sulph.,  gr.  }i-}i>  and  atropincE  suiph.,  gr.  y^, 
to  be  repeated  in  half  an  hour  if  no  improvement;  for  patients  who 
object  to  the  hypodermic  mode,  opium  in  some  form  by  the  mouth  or 
rectum,  giving  the  preference  to  the  liquid  preparations. 

Ca^nphora  and  opium  combined  often  act  well,  or  the  diarrhoea 
mixture  mentioned  on  page  78,  and  if  much  depression,  small  doses 
of  brandy  or  dry  champagne. 

The  intense  thirst  must  not  be  gratified  by  the  use  of  liquids,  but 
small  pellets  of  ice  by  the  stomach  are  grateful. 

If  the  vomiting  and  purging  continue,  make  use  of — 

Ji.     Bismuth,  subnit., gr-  xx 

Acid,  carbol., gr.  i^ 

Glycerini, gtt.  xx 

Aquae, ad f^iv.  M. 

Every  hour  or  two. 

Dr.  Hartshorne  strongly  recommends — 

5t .     Spts.  amnion,  aroraat. f^j 

Magnes.  optim., f_:^j 

Aq.  menth.  pip., f^iv.  M. 

SiG. —  ^j  every  twenty  minutes. 

If  the  case  is  seen  early,  and  if  the  diarrhoea  is  copious,  he  adds 
tinct.  opa  camph.,  f^iv,  to  the  mixture. 

The  closer  the  case  approaches  the  true  cholera  type,  the  more 
severe  are  the  muscular  crajnps,  and  their  treatment  is  indicated. 
Prof.  Da  Costa  suggests — 

R.     Chloral, _:^iv 

Cosmoline, ^j.  M. 

To  be  rubbed  over  the  affected  muscles. 

Dr.  Bartholow  suggests — 

R.     Chloral, ^iij 

Morphine  sulph., gr.  iv 

Aquoe, f^j.  M. 

SiG. —  Twenty  minitns,  hypodermically. 

Locally,  sinapis,  in  the  form  of  poultices  or  the  dry  powder,  should 
be  applied  from  the  onset. 

The  after  treatment  depends  upon  the  symptoms ;  generally  an 
acid  mixture  and  a  regulated  diet,  with  tonic  doses  of  quinina,  are 
indicated. 


DISEASES   OF  THE    INTESTINAL   CANAL.  85 

ENTERO-COLITIS. 

Synonym.     Inflammatory  diarrhoea. 

DeJBnition.  A  catarrhal  inflammation  of  the  lower  portion  of  the 
small — ihum — and  the  upper  portion  of  the  large  intestines,  with  a 
great  tendency  to  ulceration  of  the  intestinal  glands  if  the  catarrh 
becomes  chronic  ;  characterized  by  moderate  fever,  nausea,  vomiting, 
diarrhoea,  swollen  abdomen,  pain  and  emaciation. 

Causes.  Improper  and  indigestible  food  ;  summer  temperature  ; 
impure  air ;  uncleanliness  ;  exposure  to  cold  and  damp  air. 

Forms.     Acute  and  chronic. 

Pathological  Anatomy..  Acute  variety  ;  hyperaemia,  swelling, 
oedema  and  softening  of  the  mucous  membrane  of  the  lower  portion 
of  the  small  and  the  upper  portion  of  the  large  intestines,  with  hyper- 
plasia of  the  intestinal  follicles,  their  excretory  follicles  enlarged  and 
tumid,  readily  distinguished  as  grayish  or  blackish  points  in  the  mid- 
dle of  the  glands ;  the  patches  of  Peyer  are  also  enlarged,  tumefied 
and  project  above  the  level  of  the  surrounding  mucous  membrane, 
the  orifices  of  the  follicles  appearing  as  dark  points ;  these  patches 
often  have  an  ulcerated  appearance,  but  upon  close  examination 
such  is  found  not  to  be  the  case. 

Chronic  variety ;  the  thickening  and  infiltration  have  extended  to 
the  submucous  and  muscular  coats,  followed  by  induration  of  the 
tissues,  so  that  the  walls  of  the  intestines  are  often  abnormally  rigid. 
Ulceration  occurs,  which  extends  through  the  entire  thickness  of  the 
membrane.  "  These  ulcers,  when  isolated,  are  from  one  to  one  and 
a  half  inches  in  diameter,  oval  or  circular  in  shape,  and  either  have 
sharp-cut  edges,  as  though  the  piece  of  mucous  membrane  had  been 
cut  out  with  a  punch,  or  the  mucous  membrane  bounding  them  is 
undermined."  The  small  ulcers  often  coalesce,  so  that  large,  irregu- 
lar ulcerated  patches  are  formed,  having  for  their  base  the  submucous 
or  muscular  coats,  and  have  a  grayish-white  color. 

The  mesenteric  glands  are  enlarged,  but  seldom,  if  ever,  undergo 
ulceration. 

Symptoms.  Acute  form  ;  may  develop  slowly,  with  restlessness 
and  fretfulness,  or  suddenly  -with,  feverishness,  toss  of  appetite,  thirst, 
nazisea,  moderate  vomiting,  abdominal /(^z>z  /  or  rt^/^rr/^^^  may  be  the 
first  indication  of  illness  on  the  part  of  the  child.  Regardless  of  the 
character  of  the  onset,  \}[\q.  stools  soon  present  the  characteristic  appear- 
ance ;  they  are  semi-fluid,  heterogeneous,  greenish,  acid,  mixed  with 


8^  PRACTICE   OF   MEDICINE. 

yellowish  fragynents  of  ordinary  faeces,  and  tindigested  casein,  termed 
the  "  chopped  spinach  "  stools.     The  abdomen  is  enlarged  2in6.  tender. 

Emaciation  is  marked  in  proportion  to  the  severity  of  the  symptoms  ; 
in  marked  cases  the  child  is  reduced  to  a  condition  of  the  greatest 
debility  within  a  very  few  days. 

Chrofiic  form  ;  usually  follows  the  acute  form,  the  character  of  the 
symptoms  being  less  severe,  but  decidedly  persistent,  the  strength 
fails,  the  temper  is  very  irritable,  the  complexion  grows  dark,  sallow 
and  unhealthy,  the  skin  dry  and  harsh,  and  in  consequence  of  the 
marked  emaciation,  either  hangs  in  folds  around  the  shrunken  limbs, 
or  is  drawn  tightly  over  the  joints ;  the  abdomen  is  enlarged  and 
tender,  the  stools  numbering  from  six  to  a  dozen  during  the  day  and 
night,  consisting  of  the  products  of  an  imperfect  digestion  mixed  with 
mucus,  serum,  pus,  and  oftentimes  blood,  having  a  semi-fluid  con- 
sistency, and  an  extremely  offensive  odor. 

Duration.  Acute,  from  ten  days  to  about  two  weeks,  subsiding 
gradually ;  chronic,  from  one  to  two  or  three  months,  or  even  longer. 

Diagnosis.  The  acute  form  can  hardly  be  mistaken  for  any 
other  condition,  if  the  characteristic  stools  and  other  abdominal 
symptoms  are  present.  The  chronic  form  has  been  frequently  mis- 
taken for  diarrhoea  of  tuberculosis,  an  error  that  can  hardly  occur  if 
a  physical  examination  of  the  chest  has  been  made. 

Prognosis.  Always  a  very  serious  malady,  and  proves  fatal  if  it 
attacks  the  weak  during  midsummer,  or  when  surrounded  by  unfavor- 
able hygienic  conditions  ;  in  vigorous  children,  who  have  passed 
through  their  first  dentition,  the  prognosis  is  quite  favorable. 

Treatment.  For  the  acute  form,  restricting  the  amount  of  food 
for  the  first  few  days  is  of  importance.  Fresh,  pure  air,  cleanliness 
and  rest  are  also  of  great  importance. 

Any  one  of  the  following  formulae  may  be  used  with  advantage  : — 

R.     Calcii  carbon,  precip., 3J 

Tinct,  opii  camph., '^.^  ss 

Tinct.  lavanduke  comp., f^ij 

Syr.  gallae  aromat., '.S'ss 

Syr.  acaciae, f^j.  M. 

SiG. — Teaspoonful,  repeated  every  hour  or  two. 
Or— 

H.     Tinct.  opii  camph., f.^'U 

Tinct.  catechu  comp., ^.^iv 

Mistune  cretae., • fSiix* 

SiG. — One  or  two  teaspoonfuls,  every  hour  or  two. 


DISEASES   OF   THE    INTESTINAL   CANAL.  87 

Or— 

R-     Bismuth  subnit., ^iv 

Pulv.  acacise, 

Sacc.  alb aa q.  s. 

Syr.  gallae  aromat., f^j 

Spts.  vini  gallici, f^ij 

Aquas,      ad fo"J-  ^* 

SiG. — One  or  two  teaspoonfuls,  every  two  hours. 
Or— 

R.     Pulv.  ipecac, g'"-  X 

Bismuth  subnit., .    .    .ur.  v 

Cretae  pr^p., g^-  i'j-  M. 

SiG. — After  each  stool. 

Many  cases  do  well  with  pulvis  kino  comp.,  others  with  minute 
doses,  frequently  repeated,  of  acidiun  lacticum. 

Locally,  warmth  to  the  abdomen,  with  mustard,  turpentine  stupes 
or  the  spice  poultice,  made  as  follows  ;  cloves,  allspice,  cinnamon  and 
anise  seeds,  each  half  an  ounce,  pounded  (not  powdered)  in  a  mortar, 
and  placed  between  two  pieces  of  coarse  flannel  about  six  inches 
square  and  quilted  in  ;  soak  this  for  a  few  minutes  in  hot  brandy  or 
hot  whisky  and  water,  equal  parts,  and  apply  to  the  abdomen,  heat- 
ing a^ain  as  it  becomes  cool. 

Y  or  chronic  form;  carefully  regulated  diet,  rest  and  fresh  air,  and 
one  of  the  following  formulae  : — 

R .     Acidi  carbolici, gr.  yV~S" 

Tincturse  iodi, gtt.  j-ij 

Aquae  menthae, 3J.  M. 

SiG. — Every  three  or  four  hours. 
Or— 

JJ.     Tinct.  calumbae, f^iij 

Liq.  ferri  nitratis, TT^xxvij 

Syrupi  zingib., f^iij-  M. 

SiG. — One  or  two  teaspoonfuls,  according  to  age,  every  three  or  four 
hours. 

CHOLERA  INFANTUM. 

Synonyms.     Choleriform  diarrhoea  ;  summer  complaint. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  together  with  an  irritation 
of  the  sympathetic  nervous  system,  occurring  in  children  during  their 
first  dentition  ;  characterized  by  severe  colicky  pains,  vomiting,  purg- 
ing, febrile  reaction  and  prostration. 


88  PRACTICE   OF   MEDICINE. 

Cause.  Age  ;  bad  hygiene,  or  as  it  is  now  entitled,  "  civic  mala- 
ria ;  "  continuous  high  temperature ;  improper  food;  dentition;  con- 
stitutional, as  in  the  feeble,  delicate,  nervous  or  irritable. 

Pathological  Anatomy.  Resembles  closely,  if  not  identical 
with,  the  phenomena  of  catarrhal  gastritis  and  enteritis,  together  with 
a  powerful  irritation  of  the  fibres  of  the  sympathetic  system. 

Syraptonis.  The  onset  is  sudden  in  a  child  previously  well,  or 
in  a  child  suffering  from  a  bowel  affection. 

Begins  with  voiniiing,  picrgiitg,  aLbdommal/famf/ezfer,  rapid  pulse 
and  intense  thirst. 

The  vojnited  matter  is  partly  digested  food,  sero-mucus,  and  finally 
bilious,  and  is  accompanied  with  distressing  retching.  The  thirst  is  a 
marked  phenomena  of  the  disease,  and  ice  and  water  will  be  taken 
incessantly,  although  rejected  only  a  few  moments  after. 

The  stools  are  first  partly  fecal,  but  soon  watery  or  serous,  soaking 
the  clothing,  leaving  a  faint  greenish  or  yellowish  stain  ;  their  odor 
is  musty,  at  times  fetid  ;  their  number  is  from  ten  to  twenty  in  the 
day. 

Pains  precede  the  vomiting  and  purging,  colicky  in  character. 

The  fever  begins  at  once,  the  temperature  varying  from  ioi°  to 
105°,  with  morning  remissions.  1h.t  pulse  is  rapid  and  feeble,  rang- 
ing from  130  to  160. 

These  symptoms  continue  but  a  few  hours,  before  rapid  wasting 
ensues,  the  body  shrinks,  the  eyes  are  sunken  and  partly  closed,  the 
mouth  partly  open,  the  lips  dry,  cracked  and  bleeding.  The  child, 
at  first  irritable  and  restless,  passes  into  a  semi-comatose  condition, 
the  pulse  becoming  more  and  more  feeble,  the  surface  has  a  clammy 
coldness,  the  contracted  pupils  not  responding  to  light,  and  the  stupor 
deepens,  death  soon  following,  or  the  symptoms  slowly  ameliorate, 
convalescence  being  slow  and  tedious. 

Diagnosis.  The  entero-colitis  or  inflammatory  diarrhoea  of  child- 
hood is  constantly  being  mistaken  for  cholera  infantum.  The  symp- 
toms of  the  former  are :  gradual  onset ;  W\\.\\fretfulness,  loss  of  appetite, 
feverishness,  nausea,  and  moderate  vomiting,  soon  followed  by  diar- 
rhoea, the  stools  being  semi-fluid,  greenish,  mixed  with  yellowish  par- 
ticles of  faeces  and  undigested  casein,  with  a  sour  odor,  the  "chopped 
spinach  "  stools,  the  abdomen  distended  and  tender,  moderate  fever 
and  thirst,  and  having  a  duration  of  about  two  weeks. 

Prognosis.     Difficult  to  predict  the  result,  and  so  care  must  be 


DISEASES   OF  THE   INTESTINAL  CANAL.  89 

used  in  giving  a  prognosis.  The  duration  of  the  choleraic  symptoms 
is  short,  under  five  days,  but  relapses  are  common,  and  the  sequelae 
are  protracted. 

Treatment.  The  first  indication  is  to  arrest  the  vomiting  and 
purging,  for  which  use — 

R.     Bismuth  subnit., gr,  v-x 

Mucil.  acacise, J^ss 

Acidi  carbolici, gr.  j-i^-^ 

Tinct.  opii  deodorat., gtt.  j 

Mist,  cretse, ^iss.  M. 

Every  two  hours  for  a  child  between  one  and  two  years. 

Or— 

R  •     Hydrargyri  chlor.  mit., S^-  -^o 

Bismuth  subnit., gr.  ij-v.  M. 

SiG. — A  powder  every  half  hour. 

If  these  fail,  or  the  stomach  will  not  retain  them,  /z>zr/.  o^iz  may  be 
given  by  the  rectum,  with  sifici  siilph.  and  amylum. 

Cases  that  have  resisted  other  remedies  have  rapidly  improved 
under  the  following  : — 

B-     Tinct.  verat.  alb., f^^^ij 

Morphinae  acetat.,      ....        gr.  ij. 

Spts.  vini  gallici, fjij-  M. 

Et  adde  ^j  to 

Aquae  calcis, 

Aquse  menthae, aa f^j.  M. 

SiG. — One  teaspoonful,  repeated  every  hour,  if  needed. 

The  diet  must  be  restricted  in  amount :  for  the  first  day  or  two 
gtt.  v-xxx  brandy  in  barley  water  at  frequent  intervals  will  be  all 
that  is  required. 

Yor  fever,  quinijia  or  aco7iituni  are  indicated. 

For  depression,  regulated  nursing  or  feeding,  every  two  hours, 
and  water  or  ice  to  quench  the  intense  thirst,  and  cognac  brafidy, 
gtt.  x-xxx,  every  hour  or  two,  in  water. 

Locally ;  over  epigastrium,  mustard  or  a  spice  poultice,  or  turpen- 
tine stupes. 

If  the  ftervous  symptoms  become  aggravated,  small  dose  oi potassii 
bro?7zidum,  or  valerian,  which  "  reduces  the  reflex  excitability,  motility 
and  sensibility,"  is  indicated. 


90  PRACTICE   OF   MEDICINE. 

ACUTE  DYSENTERY. 

Svnonyms.     Colitis  ;  colonitis ;  ulcerative  colitis  ;  bloody  flux. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  large  intestines,  either  catarrhal  or  croupous  in  character ;  charac- 
terized by  fever,  tormina,  tenesmus  and  frequent,  small,  mucous  and 
bloody  stools. 

It  occurs  either  in  the  sporadic,  endemic  or  epidemic  form. 

Causes.  Sporadic  and  endemic  dysentery  is  caused  most  com- 
monly by  atmospheric  changes,  such  as  hot  days  with  cool  nights ; 
also  from  malarial  attacks,  and  rarely  from  errors  in  diet. 

Epidemic  dysentery  prevails  in  armies,  jails  and  tenement  houses, 
propagated  by  decomposition  of  dysenteric  stools^  and  the  unfavorable 
hygienic  surroundings. 

//  is  not  contagious. 

Pathological  Anatomy.  Sporadic  dysentery  is  catarrhal  in 
character  ;  congestion,  swelling  and  oedema  of  the  mucous  membrane 
and  sub-mucous  tissue,  with  an  over  production  of  mucus ;  the  folli- 
cles are  enlarged,  from  retention  of  their  contents,  the  result  of  the 
swelling ;  the  congested  vessels  often  rupture ;  the  mucous  membrane 
softens  in  patches,  and  is  detached,  forming  ulcers.  Recovery  follows, 
if  the  destruction  of  tissue  is  small,  smooth  cicatrices,  minus  gland 
structure,  marking  the  site. 

Epidemic  dysetitery  is  croupous  in  character ;  begins  with  intense 
congestion,  swelling,  and  oedema  of  the  mucous  and  sub-mucous  tis- 
sue, with  extravasations  of  blood  and  the  whole  mucous  membrane 
covered  with  a  firm,  fibrinous  exudation  ;  the  mucous  membrane 
softens  and  sloughs,  leaving  large  ulcers  and  gangrenous  spots.  If 
recovery  occur,  large  cicatrices  form,  which  narrow  the  calibre  of  the 
intestinal  tube. 

The  mesenteric  glands  enlarge,  soften,  and  abscesses  form  in  them  ; 
the  liver  becomes  the  seat  of  small  abscesses,  from  embolic  obstruc- 
tion of  the  radicles  of  the  portal  vein ;  the  heart  muscles  are  flabby 
and  more  or  less  fatty. 

Symptoms.  Catarrhal  form  begins  gradually,  with  diarrhoBa, 
loss  of  appetite,  nausea,  and  very  slight  fever,  which  continues  for  two 
or  three  days,  when  the  true  dysenteric  syxr\\)\.oms  develop,  to  ^\\.,pain 
on  pressure  along  the  transverse  and  descending  colon,  tormina  or 
colicky  pains  about  the  umbilicus,  bur nitig pain  in  the  rectum,  with 
the  sensation  of  the  presence  of  a  foreign  body  and  a  constant  desire 


DISEASES   OF   THE   INTESTINAL  CANAL.  91 

to  expel  it,  or  tenesmus,  which  is  almost  constant ;  the  stools  for  the 
first  day  or  two  contain  more  or  less  fecal  matter,  but  they  soon 
change  to  a  grayish,  tough,  transparefit  inucus,  containing  more  or 
less  blood  and  pus ;  during  the  tormina,  nausea  and  vomiting  may 
occur ;  the  urine  is  scanty  and  high  colored ;  the  number  of  stools 
range  from  five  to  twenty  or  more  in  the  twenty-four  hours. 

The  duration  is  about  one  week,  the  patient  being  much  emaciated 
and  enfeebled. 

The  croupous  or  epidejnic  form  sets  in  suddenly,  the  stools  being 
more  frequent,  containing  more  blood  and  pus,  with  patches  of  mem- 
brane, even  casts  of  the  bowel,  together  with  more  or  less  gangrenous 
mucotcs  membrane  ;  nausea,  vojniting,  and  great  prostration,  cold 
skin,  feeble  ptdse,  and  e7naciation  with  anxious  expression,  the  odor 
surrounding  the  patient  being  fetid. 

The  duration  of  the  grave  symptoms  is  three  or  four  days,  when 
collapse  and  death  occur,  or  slow  convalescence  begins,  continuing 
for  weeks. 

Coniplications.  Peritonitis;  hepatic  abscesses  ;  phlebitis  of  the 
intestinal  veins  ;  intestinal  perforation. 

Diagnosis.  Enteritis  lacks  the  tenesmus  and  characteristic 
stools. 

Peritonitis,  when  idiopathic,  shows  higher  temperature,  greater  ten- 
derness and  constipation. 

Prognosis.  Catarrhal  form  favorable.  Croupous  form,  the  prog- 
nosis always  grave,  for  if  recovery  does  occur  the  bowel  may  be 
crippled,  from  loss  of  structure,  or  from  narrowing  of  its  calibre,  the 
result  of  cicatrices. 

Treatment.  Emaciation  being  rapid,  the  diet  must  be  of  the 
most  nourishing  yet  bland  character,  to  which  stimulus  should  be 
added  if  much  prostration  occur. 

The  most  common  treatment  is  opium,  combined  with  one  or  more 
astringents,  to  wit : — 

R .     Ext.  opii, gr.  ss 

Plumbi  acetat., gr-  ij-  M. 

Every  two  hours ;  or — 

R .     Pulv.  opii, gr.  ss 

PlumV^i  acetat., gr-  ij 

Pulv.  ipecac, g""- j-  M. 

Every  two  hours ; 


9^  PRACTICE   OF   MEDICINE. 

Or —    R .     Pulv.  ipecac  et  opii, gr.  x 

Bismuth  subnit., gr.  xx.  M. 

Ever}'  two  hours. 

If  the  case  is  seen  early  the  very  best  prescription  possible  is — 

R.     Magnesii  sulph.,      3J 

Acid,  sulph.  dil., V\v 

Tinct.  opii  deodorat., n^x 

Aquae  menth., ,^ij.  M. 

Every  two  or  three  hours,  until  faeces  appear  in  the  stools,  when 
small  doses  of  opium  and  quini7ia  may  be  used. 

Ipecacua7iha  in  gr.  xx-xl,  is  largely  used  in  the  first  stages  of  dys- 
entery, until  the  characteristic  ipecac  stools  appear ;  the  first  doses 
being  often  rapidly  rejected  by  the  stomach,  the  treatment  is  difficult 
to  pursue  outside  of  hospital  practice ;  but  of  its  efficacy  in  many 
cases  there  can  be  no  doubt. 

Dr.  Loomis  speaks  strongly  of  ipecaua?tha,  gr.  %.  every  half-hour, 
with  sufficient  opium  to  secure  quietness. 

Ringer  recommends  hydrargyri  chloridum  corrosivum,  gr.  ^^, 
every  hour  or  two,  which  "  rarely  fails  to  free  the  stools  from  blood 
and  slime,  although  in  some  cases  a  diarrhoea  of  a  different  character 
may  continue  for  a  short  time  longer." 

In  children  the  following  combination  is  efficacious : — 

R  .     Pulv.  ipecacuanha, SV-  /^ 

Bismuth  subnit., gr.  v 

Cretse  prep., gr-  "j*  M- 

SiG. — Every  two  hours. 

The  patient  should  be  confined  to  bed  in  even  the  mildest  attacks, 
and  the  stools  removed  at  once  and  disinfected. 

Washing  out  the  rectum  with  either  tepid,  hot,  cold,  or  iced  water, 
as  suggested  by  Prof.  Da  Costa,  adds  greatly  to  the  patient's  comfort 
and  to  the  decrease  of  the  inflammatory  process. 

Lingering  or  chronic  cases  are  benefited  by  one  or  any  of  the  fol- 
lowing remedies  :  Terebinthina,  acidum  carbolicum,  argentum  7tiiras, 
cupri  siclphas,  or  zinci  oxidum. 


DISEASES   OF   THE   INTESTINAL  CANAL.  93 

TYPHLITIS. 

Synonyms.     Inflammation  of  the  caecum;  catarrh  of  the  caecum. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  caecum  and  ascending  colon ;  characterized  by  pain,  tender- 
ness, constipation,  and  in  certain  cases  a  characteristic  vomiting. 

Causes.  In  a  majority  of  cases  mechanical,  from  the  lodgment 
of  seeds  or  hardened  faeces. 

Pathological  Anatomy.  Similar  to  the  catarrhal  inflammation 
of  dysentery. 

Symptoms,  Pain  and  tenderness  in  the  right  iliac  fossa  and 
along  the  ascending  colon,  with  some  prominence  of  this  region;  the 
bowels  are  usually  constipated,  or  small  liquid  stools  may  occur  from 
time  to  time,  due  to  the  accumulation  of  hardened  faeces  in  the  saccu- 
lated periphery  of  the  caecum,  leaving  a  central  canal  through  which 
the  liquid  contents  of  the  upper  bowel  can  pass. 

In  severe  cases,  "the  \0c2l  pain,  tenderness  2ind.  swelling  zxq  greater, 
there  are  impaction  oi  fceces  and  no  movements.  There  are  decided 
fever,  restlessness,  and  also  nausea  and  vomiting.  The  vomited  mat- 
ters, at  first  the  contents  of  the  stomach,  then  the  duodenum,  with 
bilious  matter,  and  ultimately,  if  the  impaction  persists,  of  material 
having  the  odor  of  faeces.  With  these  symptoms  occux  great  depres- 
sion of  the  vital  powers.  Peritonitis  is  finally  developed  by  contiguity 
of  tissue  or  by  rupture  of  the  bowel." 

Duration.  The  mild  form  lasts  about  one  week.  The  severe 
form  may  terminate  in  subacute  peritonitis,  continuing  about  two 
weeks. 

Diagnosis.  The  mild  form  is  distinguished  from  other  intestinal 
affections,  by  the  localized  pain,  tenderness  and  prominence,  and  the 
constipation. 

The  severe  form  can  only  be  distinguished  from  the  other  forms  of 
intestinal  obstruction  by  the  history  of  the  case  and  attack,  and  the 
results  of  treatment. 

Prognosis.  Mild  for?n  idiVorzhlQ.  Severe  for tn  gxdiYe.,  2L\ih.owgh. 
not  necessarily  fatal. 

Treatment.  The  patient  should  be  kept  in  bed,  and  placed  on  a 
strictly  milk  diet. 

In  mild  cases,  act  upon  the  bowels,  with  either  oleum  ricini  or  mag- 
nesii  sulphas  in  small  doses,  followed  by  an  opium  influence,  to  be 
maintained  until  convalescence  is  pronounced. 


94  PRACTICE   OF   MEDICINE. 

In  severe  cases,  begin  an  opium  influence  at  once,  by  hypodermic 
injections  of  morphina  guarded  with  atropiiia,  continued  until  all 
symptoms  of  inflammation  have  subsided,  when  attempts  to  remove 
the  accumulated  faeces  may  be  made  by  irrigation  of  the  bowel  with 
warm  soapsuds,  and  the  cautious  administration  of  viagnesii  sulphas 
in  drachm  doses,  every  two  hours. 

If  suppuration  develop,  laparotomy  with  strict  ^«//J(?//zV  precautions 
is  the  indication. 

Locally.  Leeches  over  the  caecum  followed  by  hot  fomentations  or 
ice  bags,  or  cold  compresses. 


PERITYPHLITIS. 

Synonyms.  Perityphlitic  abscess ;  suppurative  appendicitis ; 
pericaecal  abscess. 

Definition.  An  acute  inflammation  of  the  connective  tissue 
around  the  caecum,  tending  to  the  formation  of  an  abscess ;  charac- 
terized by  pain,  swelling,  and  febrile  reaction. 

Causes.  Injuries  to  the  abdomen  over  the  caecum  ;  and  also 
extension  of  the  inflammation  from  the  caecum  by  perforation.  Often 
occurs  with  typhlitis. 

Symptoms.  Begins  with  2^  feeling  of  weight,  soreness  3.nd  parox- 
ysms of  acute  pain  extending  into  the  hip,  thigh  and  abdomen,  with 
the  development  of  a  hard  swelling  in  the  right  iliac  region.  Its 
special  tendency  is  toward  suppuration,  which  is  announced  by  irreg^ 
ular  chills,  feverishness,  and  sweats,  and  a  feeling  of  tensiott  and 
throbbing.  Its  development  is  slow,  and  if  associated  with  typhlitis 
the  symptoms  of  that  affection  are  added. 

Diagnosis.  Differs  from  typhlitis  by  the  absence  of  the  colicky 
pains,  dyspeptic  symptoms,  costive  bowels,  and  tympanites  preceding 
the  development  of  a  tumor  ;  in  perityphlitis  the  tumor  is  present  with 
the  development  of  the  symptoms. 

Psoas  abscess  is  not  associated  with  intestinal  symptoms,  and  the 
discharge  is  free  from  a  fecal  odor.  Rental  and  ovarian  tumors  should 
not  be  sources  of  error.  The  possibility  of  hernial  tumors  must  not 
be  overlooked. 

Treatment.  If  not  associated  with  typhlitis,  the  treatment  is  to 
allay  the  inflammation  in  the  first  stage,  by  either  ice,  locally,  or  freely 
painting  with  tinctura  iodi  ;  if  suppuration  is  evident,  hasten  hy  poul- 


DISEASES   OF   THE    INTESTINAL  CANAL.  95 

tices,  and  follow  by  evacuation  of  the  pus  with  the  aspirator  or  2.  free 
opening,  conjoined  with  the  use  of  opium  and  quinina. 

If  the  disease  is  not  rapidly  controlled,  a  laparotomy  with  strict 
antiseptic  precautions  is  indicated. 


PROCTITIS. 

Synonyms.     Catarrh  of  the  rectum  ;  dysentery  ;  rectitis. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  rectum  and  anus  ;  characterized  by  pain,  tenesmus  and  frequent 
stools  of  hardened  faeces,  or  of  mucus,  pus  and  blood. 

Causes.  Chief  cause  constipation  ;  also  sitting  on  damp  ground 
or  stone  steps  ;  habitual  use  of  enemata  or  of  purgatives  ;  diseases  of 
the  liver. 

Patholog'ical  Anatomy.  Similar  to  those  occurring  in  catar- 
rhal dysentery. 

Symptoms.  Uneasy  sensations  and  burning  in  the  rectum,  with 
a  constant  desire  for  stool,  or  tenesjnus,  often  so  severe  as  to  cause  a 
prolapse  of  the  mucous  membrane.  The  stools  may  be  either  hard- 
ened fceces  or  scybala  from  the  distended  colon,  which  cause  inte?ise 
pain  when  they  reach  the  rectum ;  or  the  stools  may  be  of  mucus, 
muco-pus  or  bloody  or  blood-streaked.  Generally  there  are  present 
nausea,  especially  during  the  tenesmus,  headache,  feverishness  and 
malaise.  In  severe  cases  there  is  strangury ,  and  with  the  tenesmus, 
straining  with  urination. 

If  the  case  be  protracted  and  severe,  inflammation  of  the  con- 
nective tissue  around  the  rectum  occurs,  causing  periproctitis,  which 
usually  terminates  in  various  kinds  of  fistulae. 

Complications.     Periproctitis ;  peritonitis  ;  hepatic  abscesses. 

Diagnosis,  In  ?nales,  the  disease  cannot  be  confounded  with 
any  other  affection,  save,  perhaps,  hemorrhoids.  In  females,  dis- 
placements of  the  uterus  may  somewhat  simulate  the  symptoms  of 
proctitis. 

Prognosis.  Uncomplicated  cases  favorable.  Either  of  the  com- 
plications adds  greatly  to  the  gravity  of  the  affection. 

Treatment.  In  cases  due  to  constipation  the  chief  indication  is 
to  empty  the  bowels,  for  which  the  magjiesia  mixture  mentioned  for 
dysentery  is  the  most  suitable  remedy ;  after  which  emollient  ene- 
mata, with  opiujn,  are  indicated.     Irrigation  of  the  bowel  with  warm 


%  PRACTICE   OF   MEDICINE. 

water  once  or  twice  daily  assists  in  the  liquefaction  of  the  hardened 
faeces.  Either  enemata  or  suppositories  oi glyceri?iwn  should  answer 
in  certain  cases. 

Cases  other  than  those  due  to  constipation,  emollient  enemata  and 
opium,  one  of  the  best  being — 

R  .     01.  olivx, ^  ij 

Tinct.  opii  deodorat., TT\,xv.  M. 

If  symptoms  oi  periproctitis  occur,  use  ice  to  the  parts,  and  if  sup- 
puration ensue,  evacuation  by  a  free  opening  and  quinina. 


INTESTINAL  OBSTRUCTION. 

Synonyms.  Intestinal  occlusion ;  strangulated  hernia  ;  invagi- 
nation ;  intestinal  stricture  ;  ileus. 

Definition,  A  sudden  or  gradual  closure  of  the  intestinal  canal  ; 
characterized  by  pain,  nausea,  vomiting,  constipation,  and  finally 
collapse. 

Causes.     The  numerous  causes  are  arranged  as  follows  : — 

1.  Accumulations  withift  the  bowel,  of  hardened  faeces,  or  foreign 
bodies. 

2.  Strictures,  the  result  of  cancer,  ulceration,  or  cicatrices. 

3.  Pressure  against  the  bowel,  from  peritoneal  adhesions,  tumors, 
and  abnormal  growths. 

4.  Stra7igulations ,  due  to  the  numerous  forms  of  hernia. 

5.  Invagination  or  intussusception,  the  most  common. 

6.  Twisting,  volvulus  or  rotation  of  the  bowels. 
Pathological  Anatomy,     hivagijtation  is  the  only  form  calling 

for  special  description.  It  is  usually  caused  by  the  lower  portion  of 
the  ileum  slipping  down  into  the  caecum,  as  the  finger  of  a  glove 
might  be  invaginated,  causing  thus  an  actual  mechanical  obstruction  ; 
this  is  produced  by  a  spasm  of  the  ileum,  whereby  its  calibre  is  greatly 
diminished,  thus  permitting  its  descent  into  the  lower  bowel.  Result- 
ing from  this  occlusion  or  compression  are  congestion,  inflammation, 
with  secondary  constitutional  reaction  and  death,  or  more  rarely  the 
invaginated  bowel  sloughs  off,  and  is  voided  by  stool,  union  taking 
place  at  its  site  and  recovery  following. 

Symptoms.  The  onset  of  the  symptoms  may  be  either  sudden 
ox  gradual,  and  are  as  follows  : — 


DISEASES   OF  THE    INTESTINAL  CANAL.  97 

Constipation,  with  more  or  less  severe  colicky  pains,  not  relieved  by 
either  purgatives  or  injections ;  feeling  of  weight  and  soreness  with 
distention  of  the  abdomen  and  naiisea  and  vomiting ;  the  symptoms 
all  grow  more  pronounced,  the  pain  becoming  violent,  tetiderness  in 
limited  areas,  the  vomiting  becoming  stercoraceoiis,  the  abdomen  hard 
and  tense,  the  eyes  siitiken,  the  pulse  quick  and  feeble,  the  skin  cold 
and  covered  with  a  clammy  sweat.  The  above  continue  more  or  less 
pronounced  for  a  week  or  ten  days,  when  collapse  and  death  occur, 
or  more  rarely  there  is  a  gradual  return  to  health. 

Cases  occur  rarely  in  which  small,  fecal,  muco-purulent  stools  con- 
taining more  or  less  blood  exist,  instead  of  constipation. 

Diagnosis.  One  of  the  most  difficult,  and  can  only  be  solved  by 
a  careful  study  of  the  case  along  with  the  different  causes  producing 
the  affection.  The  site  of  the  occlusion  can  rarely  be  determined 
positively. 

Intestinal  obstruction  may  be  mistaken  for  i7itestinal  colic,  hernia, 
enteritis,  peritonitis,  hepatic  or  renal  colic. 

Prognosis.  Always  grave,  but  guided  by  the  cause.  Impacted 
fceces  favorable.  Invagination  less  favorable,  but  recoveries  occur ; 
the  longer  the  symptoms  continue,  the  more  favorable  the  outlook. 
Strangulations  unfavorable,  but  many  recoveries  recorded.  Strict- 
ures, due  to  cancer,  cicatrized  ulcers  and  the  like,  are  the  most 
unfavorable. 

Treatment.  Stop  all  forms  of  purgatives  as  soon  as  the  diagnosis 
of  obstruction  is  determined. 

Opium  is  indicated  in  all  forms  with  pain,  and  is  best  administered 
in  the  form  of  morphina,  combined  with  small  doses  of  atropina, 
hypodermically. 

The  author  has  seen  the  most  brilliant  results  follow  the  plan  of 
wasJmig  out  the  stomach  as  suggested  by  Kiissmaul,  and  with  full 
doses  of  atropina  hypodermically,  for  its  action  on  intestinal  peristal- 
sis, and  with  electricity,  one  pole  over  abdomen,  the  other  in  rectum. 

Cases  resulting  from  impacted  faeces  are  rapidly  cured  by  the  above 
plan  combined  with  irrigation  of  the  lower  bowels  with  tepid  soap- 
suds. 

If  invagination,  raising  the  buttocks  and  lowering  the  chest,  and 
repeated  ittjections  of  warmed  oil,  are  recommended. 

Distention  of  the  bowel  by  pwnping  air  through  long  rectal  tubes, 
or  disengaging  carbonic  acid  gas  in  the  bowel,  by  first  injecting  a 
8 


98     '  PRACTICE   OF   MEDICINE. 

solution  of  sodii  bicarbonas,  and  follow  this  with  a  solution  of  acidinn 
tartaricitm,  about  one  drachm  of  each,  pressure  being  made  against 
the  anus,  to  prevent  escape ;  but  the  danger  of  rupture  of  the  bowel 
must  not  be  overlooked. 

Flatulent  distention  can  be  removed  by  the  long  aspirator  needle. 

Laparotomy  is  no  doubt  the  operation  of  the  future,  when  our 
means  of  diagnosticating  the  location  of  the  trouble  is  more  exact. 

The  nutritioti  of  the  patient  is  best  attained  by  injections  of  either 
peptonized  foods  or  defibrinated  blood,  or  both. 


INTESTINAL  PARASITES. 


TAPEWORMS. 

Varieties.  Tcenia  solium ;  Tcsnia  sagiftata ;  Bothriocephalus 
latus. 

Causes.  The  Tcznia  solium,  the  "  armed  tapeworm,"  is  the  most 
common  in  this  country.  It  is  derived  from  the  embryos  contained 
in  pork,  known  as  the  cysticercus  cellulosus. 

The  Tcenia  saginata,  the  "unarmed  tapeworm,"  a  not  uncommon 
variety,  is  derived  from  the  embryos  contained  in  beef,  known  as 
cysticercus  bovis. 

The  Bothriocephalus  latus,  also  "an  unarmed  tapeworm,"  the 
largest  parasite  infesting  man,  is  supposed  to  be  derived  from  an 
embryo  found  vafish. 

The  embryo  or  ova  is  introduced  into  the  intestinal  canal  with  the 
food  and  drink.  The  parasite  reaches  its  final  growth  after  its  en- 
trance into  the  intestines. 

Those  handling  fresh  meats  or  eating  uncooked  animal  food  are 
most  liable  to  be  affected. 

Uncleanliness  is  also  an  important  factor. 

Description.  The  tcetiia  solium  is  from  six  to  thirty  feet  in  length, 
has  a  globular  head,  or  scolex,  a  slender  neck  connecting  its  numer- 
ous flat  segments  or  joints.  The  head,  or  scolex,  measures  about  -^^ 
of  an  inch,  has  a  double  circle  of  booklets, — whence  the  term  "  armed 
tapeworm," — and  is  provided  with  from  two  to  four  suckers.  The  seg- 
ments or  joints  {strobila)  are  flat,  and  vary  from  one-eighth  to  one- 


INTESTINAL   PARASITES.  99 

half  an  inch  in  length,  and  each  contain  both  male  and  female  sexual 
organs,  the  uterus  being  a  long,  numerously  branched  tube,  in  which 
the  ova  develop ;  the  ova  measure  about  yJ^o  of  an  inch  in  diameter. 
An  .ordinary  tapeworm  contains  some  five  million  ova. 

The  parasite  is  firmly  imbedded  in  the  mucous  membrane  of  the 
upper  third  of  the  small  intestines  by  its  booklets  and  suckers. 

The  lower  or  terminal  segments  represent  the  adult  and  complete 
animal,  and  are  termed  the  proglottides,  which  separate  from  the 
parasite  and  are  discharged  either  alone  or  with  the  f^ces. 

The  tcBnia  saginata  is  from  ten  to  forty  feet  in  length,  has  a  rounded 
or  oval-shaped  head,  measures  about  -^^  of  an  inch  and  has  four 
strong  and  prominent  suckers,  but  no  booklets, — whence  the  term 
"  unarmed  tapeworm  ;  "  the  neck  is  short  and  thick  and  the  segments 
are  larger,  stronger  and  thicker  than  those  of  the  T.  solium. 

The  Bothriocephalus  latus  is  the  largest  of  the  three  Cestoda,  the 
length  ranging  from  fifteen  to  sixty  feet,  the  head  oval,  measuring 
about  ^  of  an  inch,  a  short  neck,  the  segments  or  joints  being  nearly 
three  times  as  broad  as  they  are  long.  Its  color  is  a  dull,  bluish-gray. 
Zoologically  considered,  this  variety  is  not  a  true  tapeworm. 

Symptoms.  Not  unfrequently  a  tcenia  produces  no  symptoms 
whatever. 

Usually,  however,  there  are  colicky  pains  throughout  the  abdomen, 
inordinate  appetite,  disorders  of  digestion,  emaciation,  constipation, 
attacks  of  cardiac  palpitation,  faintness,  disorders  of  the  special  senses 
and  pruritus  of  the  anus  and  nose.  Any  or  all  of  these  symptoms 
may  be  present. 

A-  large  meal  will  often  remove  the  majority  of  the  symptoms 
present. 

In  a  large  number  of  cases  the  discovery  of  the  segments  is  the  first 
intimation  of  the  presence  of  the  parasite. 

Treatment.  A  number  of  remedies — termed  taeniafuges — are 
used  more  or  less  successfully  for  the  expulsion  of  the  tapeworm,  to 
wit:  extractum  granati  rad.  cort.  fiuidum,  f^ss-ij,  or  a  decoctum 
granati  rad.  cort.  (5ij  bark  of  root,  aquas  Oj),  wineglassful  every 
hour  until  all  is  taken,  as  suggested  by  Prof.  Bartholow  ;  or  oleoresifia 
aspidii,  5ss  doses  repeated,  or  oleum  pepo  express.,  3j-iv.  followed 
by  oleum  ricini.  Creosota  has  been  successful  in  a  number  of  cases. 
Several  cures  are  reported  {xoxvl glycerinum,  f3ij-5J,  repeated  p.  r.  n, 

A  much  pleasanter  remedy  is  pelletierine,  the  active  constituent  of 


lOQ  PRACTICE   OF    MEDICINE. 

granatin}!,  used  in  the  form  of  the  tafmate,  gr.  x-xx,  or  Tanrefs  solu- 
tion of  pelletierine. 

Cases  which  resist  these  nieans  are  often  cured  by  the  following  : — 

B; .     Chloroformi, 

Ext.  aspidii  fid., aa f^j 

Emul.  olei  ricini,  .    .    .    .  (B.  Ph.)  .    .    .    .     5iij.  M. 

SiG. — To  be  taken  in  the  early  morning ;  no  food  until  after  thorough 
action  of  the  bowels. 

An  important  precaution  in  the  management  is  close  attention  to 
the  "preparatory  treatment"  rendered  essential  to  remove  the  mucus 
in  which  the  head  (scolex)  is  imbedded.  It  consists  in  the  adminis- 
tration of  a  good  purgative  for  one  or  two  days,  and  a  light  diet,  such 
as  milk  and  broths,  preceding  the  use  of  the  tceniafuge. 


ROUND  WORMS. 

Varieties.     Ascaris  lumbricoides  ;  Oxyuris  ver?nicularis. 

Causes.  The  ascaris  hunbricoides  is  one  of  the  most  common  of 
the  parasites  affecting  the  human  family,  and  develops  in  the  intes- 
tines, either  after  the  entrance  of  the  ova  of  the  same,  or  from  the  so- 
called  "  intermediate  parasites."  Their  entrance  is  effected  by  means 
of  the  food  and  drink. 

The  oxyicris  vermicularis  develops  in  the  large  intestines,  from 
either  its  peculiar  ova,  or  the  so-called  "  intermediate  parasite,"  these 
finding  their  way  into  the  bowel  with  the  food  and  drink,  or  by  direct 
contact. 

Description.  The  ascaris  lumbricoides,  or  the  round  worm,  is  of 
a  brown  color,  a  cylindrical  body,  from  ten  to  twenty  inches  in  length 
and  from  an  eighth  to  a  fourth  of  an  inch  in  circumference  ;  the  head 
terminates  in  three  semilunar  lips,  each  having  about  two  hundred 
teeth.  The  ova  are  oval-shaped,  are  produced  in  immense  numbers, 
some  sixty  million  in  a  mature  female,  have  wonderful  vitality,  resist- 
ing extreme  heat  or  cold. 

The  round  worjn  inhabits  principally  the  small  intestines,  although 
it  often  migrates  to  other  parts.  They  are  found  in  numbers  from  one 
to  several  hundred. 

The  oxyuris  vermicularis,  thread  or  seat  worm,  resembles  an  ordi- 
nary piece  of  white  thread,  measuring  from  a  sixth  to  a  half  inch  in 
length,  the  head  terminating  in  a  mouth  with  three   lips,  the   tail 


INTESTINAL   PARASITES.  101 

terminating  as  a  sharp  point.  The  ova  are  oval,  produced  in  large 
numbers,  each  female  containing  about  ten  thousand,  are  surrounded 
by  a  stout  envelope,  which  increases  their  vitality. 

The  seat  worm,  as  its  name  indicates,  inhabits  the  large  intestines, 
especially  the  rectum,  although  they  frequently  migrate  to  the  sexual 
organs.  They  vary  in  number,  sometimes  the  parts  frequented  being 
entirely  covered. 

Sjrmptoms.  The  ascaris  lumbricoides,  or  round  worm,  may  be 
present  in  great  numbers  and  yet  produce  no  characteristic  symptoms 
other  than  gastric  and  intestinal  irritation,  such  as  picking  the  nose, 
foul  breath,  colicky  pains,  nausea  and  vomiting,  diarrhoea  and  dis- 
turbed sleep,  such  as  tossing  from  side  to  side  of  bed  and  grinding 
the  teeth.  Any  or  all  of  these  symptoms  may  be  present  or  absent, 
the  only  positive  proof  being  the  passage  of  the  parasite. 

The  oxytiris  ver?nicularis,  or  seat  worm,  produces  intense  itching 
about  the  anus,  with  a  desire  for  stool,  the  passage  often  containing 
much  mucus,  the  result  of  the  irritation  produced  by  their  presence. 
Should  they  migrate  to  the  sexual  organs,  intense  itching  of  these 
parts  result,  which,  unless  speedily  corrected,  leads  in  children  to 
masturbation. 

Treatment.  The  ascaris  lumbricoides  are  readily  removed  by 
the  following  "  worm  powder  "  : — 

R.     Santonini, gr.  X-j-ij 

Hydrargyri  chlor.  mite, gr.  ^-ij.         M. 

Ft.  chart. 

SiG. — At  bedtime,  followed  by  a  dose  of  oleum  ricini  before  breakfast. 

For  the  oxyuris  vermicularis  the  above  santonimim  powder,  with 
the  use  of  enetnata  of  quassia,  alumen,  sodii  chloridtan,  or  R.,  acidi 
carbolici,  gr.  v-x,  aqu83,  Oj,  according  to  the  age,  the  injection  not  to 
be  retained.  Washing  the  anus  and  external  genitals  with  a  solution 
of  acidum  carbolicum  should  also  be  employed. 


102  PRACTICE   OF   MEDICINE. 

DISEASES  OF  THE  PERITONEUM. 


PERITONITIS. 

Synonym.     Inflammation  of  the  peritoneum. 

Definition.  A  fibrinous  inflammation  of  the  peritoneum,  either 
acute  or  chronic  in  character,  characterized  by  fever,  intense  pain, 
tenderness,  tympanites,  vomiting  and  prostration.  It  may  be  limited 
to  a  part — local,  or  it  may  involve  the  whole  membrane — general, 
peritonitis. 

Causes.  Acute  variety :  Intense  cold ;  protracted  irritation  by 
blisters  ;  blows  upon  the  abdomen  ;  inflammation  or  perforation  of 
the  stomach,  intestines,  gall  or  urinary  bladder  ;  vermiform  appendix 
or  inflammation  of  this  part  or  the  surrounding  parts  ;  inflammation 
of  the  pelvic  viscera  ;  septicaemia  or  pyaemia ;  erysipelas  ;  hernia. 

Many  surgeons  doubt  that  peritonitis  is  ever  an  idiopathic  disease, 
but  that  rarely  it  does  so  occur  is  certain. 

Chronic  variety  :  Tuberculosis  ;  albuminuria  ;  scrofula  ;  cancer ; 
sclerosis  of  the  liver. 

Pathological  Anatomy.  Acute  form  :  hypersemia  of  the  serous 
membrane,  the  capillaries  distended  and  occasional  extravasations  of 
blood  from  their  rupture;  the  normal  secretion  is  arrested,  and  the 
shiny  membrane  becomes  dull  and  opaque,  from  an  exudation  of  pure 
fibrin,  which  is  adhesive,  gluing  the  parts  together  ;  if  the  inflam- 
matory action  is  now  arrested,  it  is  termed  adhesive  peritonitis ;  if, 
however,  the  action  progress,  an  effusion  of  serous  fluid  is  poured 
out  into  the  peritoneal  cavity,  the  amount  varying  from  a  few  ounces 
to  several  gallons  ;  this  is  termed  exudative  peritonitis.  If  recovery 
result,  the  fluid  is  absorbed,  with  much  of  the  solid  exudation,  the 
unabsorbed  portions  forming  adhesions  between  the  membrane  and 
the  different  abdominal  organs,  often  causing  great  deformity  and 
irregularity  in  their  relations.  Pus  develops  if  the  absorption  is  not 
prompt  or  if  any  cachexia  be  present. 

The  chronic  form  follows  the  acute,  or  is  associated  with  tubercu- 
losis, scrofula,  Bright's  disease  or  sclerosis  of  the  liver. 

The  membrane  is  irregularly  thickened  and  opaque,  with  strong 
adhesions  to  one  or  more  coils  of  the  intestine,  the  liver  or  spleen  ; 
the  quantity  of  fluid  present  is  small,  purulent  or  sero-purulent  in 
character,  and  encysted  by  the  agglutinated  membrane. 


DISEASES   OF   THE   PERITONEUM.  103 

Symptoms.  Acute  form  ;  when  idiopathic,  the  onset  is  sudden, 
with  a  chill,  fever,  \02-'^ ,  pulse  100-140,  wiry  and  tense,  severe  pain, 
cutting  or  boring  in  character,  and  tenderness,  becoming  so  great  that 
the  shghtest  touch  aggravates  it,  the  decttbitus  being  on  the  back,  with 
flexed  thighs  ;  the  abdomen  is  distended  and  rigid,  from  constipation, 
effusion  and  meteorism ;  the  diaphragm  is  pushed  up  as  far  as  the 
third  or  fourth  rib  in  severe  cases,  causing  compression  of  the  lungs, 
and  displacement  of  the  heart,  liver  and  spleen.  There  is  impaired 
appetite,  and  nausea  and  vomiting  are  almost  constant,  as  is  hiccough. 
It  is  a  clinical  fact  that  a  sub-normal  temperature  is  of  frequent 
occurrence  in  acute  peritonitis. 

Secondary  form,  from  extension,  begins  with  local  and  gradually 
increasing  pain,  the  temperature  increases,  tense  pulse  and  vomiting. 
li  from  perforatioji,  it  is  announced  by  severe  pain  and  all  the  symp- 
toms of  shock.     If  pus  forms,  symptoms  of  hectic  develop. 

These  symptoms  continue  from  six  to  eight  days,  when  they  begin 
to  ameliorate  and  a  tedious  convalescence  ensues,  or  pain  and  tender- 
ness grow  more  marked,  strength  fails,  surface  cold,  pulse  rapid,  and 
collapse,  with  hippocratic  face,  to  wit :  anxious  expression,  pinched 
features,  sunken  eyes  and  drawn  upper  lip. 

Chronic  form  :  irregular  chills,  fever  znd  sweats;  distended  abdo- 
men, constipation,  alternating  with  diarrhoea ;  diffused  tefiderness, 
\f'\\.h.  points  of  i?itenseness  and  hardness  ;  colicky  pai?ts  during  diges- 
tion, rapid  emaciation  and  failure  of  strength.  Usually  the  lower 
portions  of  the  abdomen  give  a  dull  note  on  percussion,  from  the 
presence  of  fluid,  or  scattered  points  of  dullness,  showing  the  presence 
of  encysted  fluid. 

Diagnosis.  The  question  of  diagnosis  in  this  disease  is  of  great 
importance,  as  it  so  frequently,  if  not  always,  is  associated  with  the 
diseases  and  accidents  of  the  abdomen.  Acute  gastritis  differs  from 
peritonitis  in  having  a  history  of  corrosive  poisoning,  severe  pain, 
limited  to  the  stomach,  with  early  and  severe  vomiting  ;  while  the 
latter  has  fever,  diffused  abdominal  pain  and  tenderness,  with  decided 
distention. 

Acute  enteritis  has  localized  pain  and  tenderness  with  marked 
diarrhoea ;  constipation  being  the  rule  in  peritonitis. 

Rheumatism  of  the  abdominal  muscles  occurs  with  a  rheumatic  his- 
tory, is  subacute,  lacks  the  great  abdominal  distention  of  peritonitis, 
and  while  tenderness  exists,  it  is  not  aggravated  by  deeper  pressure. 


104  PRACTICE   OF   MEDICINE. 

Biliary  colic,  or  the  passage  of  a  gall-stone,  has,  as  a  prominent 
symptom,  excruciating  pain,  locahzed  over  the  common  bile  duct, 
which  is  of  a  paroxysmal  character  and  followed  by  jaundice.  In 
renal  colic  the  acute  pain  follows  the  course  of  the  ureters,  with  re- 
tracted testicle  and  altered  urinary  secretion. 

Prognosis.  Idiopathic  cases  favorable,  and  especially  if  they 
continue  longer  than  a  week,  as  fatal  cases  usually  end  during  the 
first  week.     Cases  from  perforation  unfavorable. 

Chronic  peritonitis  being  generally  of  tuberculous  origin,  the  prog- 
nosis is  unfavorable,  although  partial  or  complete  recovery  results  in 
the  cases  following  the  acute  form  of  the  disease. 

Treatment.  Actcte  form  :  Idiopathic  and  robust  cases,  locally, 
leeches  or  wet  cups,  followed  by  cold  or  hot  applications,  as  most 
agreeable  to  the  patient,  or  covering  the  abdomen  with  a  blister  ; 
adynamic  cases,  dry  cups,  followed  by  warm  applications  medicated 
with  tinctura  opii. 

The  profession  are  divided  between  two  plans  of  treatment  of  peri- 
tonitis, one  side  favoring  opium  and  the  other  party  as  strongly  urging 
saline  purgatives  and  laparotomy. 

Prof.  Da  Costa  says  opium  and  guittifta  are  the  remedies  indicated 
at  the  onset  of  the  disease,  to  wit :  at  once  hypodermic  of  jnorphina, 
gr.  X~/^»  maintaining  the  effect  by  hourly  doses  of  either  ?norphina 
or  opium,  by  the  mouth.  Prof.  Clark  ascertained  the  tolerance  of 
opium  in  this  disease,  by  the  tremendous  amounts  used  in  a  case 
under  his  care  ;  the  first  day  he  gave  200  grs.,  the  second  day  472  grs., 
the  third  day  236  grs.,  fourth  day  120  grs.,  fifth  day  54  grs.,  sixth  day 
22  grs.,  and  on  the  seventh  day  8  grains.  Prof.  Clark  found  that, 
as  a  rule,  however,  jnorphina,  gr.  ye-%,  every  two  hours,  would 
maintain  the  effects  of  the  drug.  The  opium  should  be  guarded 
with  sufficient  doses  of  atropina.  Quinina,  gr.  v,  every  four  hours 
until  exudation,  after  which  gr.  ij,  four  times  a  day,  is  of  marked 
benefit. 

While  the  opium  treatment  places  the  patient  as  well  as  the  bowels 
"in  splints"  and  relieves  the  pain,  it  is  urged  by  the  advocates  of 
saline  purgatives,  however,  that  instead  of  locking  up  the  bowels,  the 
use  of  salines  puts  the  bowels  into  active  peristaltic  action,  thereby 
the  peritoneal  cavity  is  drained  of  the  products  of  inflammation  and 
the  inflamed  surfaces  are  relieved  of  all  engorgement  by  a  thorough 
depletion  of  the  vessels  in  the  intestinal  walls,  the  pulse  and  temper- 


DISEASES   OF   THE   PERITONEUM.  105 

ature  are  improved,  the  pain  is  lessened  as  quickly  as  by  opium,  and 
the  formation  of  adhesions  and  bands  is  prevented. 

Should  the  active  symptoms  continue  under  either  plan  of  treat- 
ment, laparotomy  with  strict  antisepsis  is  indicated. 

The  decline  of  vital  powers  must  be  averted  by  regulated  nutri- 
tion, diVidfree  stimulation. 

Locally,  an  ointment  of  belladonna  and  hydrargyrum,  are  of  advan- 
tage. 

During  convalescence,  perfect  quiet,  nourishing  diet,  moderate  stim- 
ulation, scattered  flying  blisters,  and  the  following — 

5c .     Potassii  iodidi, gr.  v-x 

Ferri  pyrophos., gr.  ij 

Tinctura  lavandulae  comp., TT\^xv 

Aquae  destillat£e, ad  ....  ^ij.  M. 

Every  six  hours. 

should  constitute  the  treatment,  with  tonic  doses  of  guinina. 

Peritonitis  from  perforation,  absolute  quiet,  hypodermic  injections 
of  morphina,  ice  locally,  and  stimulants  per  mouth,  rectum,  or  hypo- 
dermicaliy,  and  laparotomy. 

Chronic  peritonitis ;  locally  tinctura  iodi,  and  internally  opium,  for 
pain ;  potassii  iodidum  as  an  absorbent,  with  nourishing  diet,  oleum 
7norrhua>  and  stimulants,  and  rest  in  bed. 


ASCITES. 

Synonyms.     Dropsy  of  the  abdomen  ;  peritoneal  dropsy. 

Definition.  A  collection  of  serous  fluid  in  the  abdomen,  or  more 
correctly  in  the  peritoneal  cavity  ;  characterized  by  swollen  abdomen, 
fluctuation,  dullness  on  percussion,  displacement  of  viscera,  embar- 
rassed respiration,//?^^  the  symptom.s  of  its  cause. 

Causes.  Ascites  may  form  part  of  a  general  dropsy,  to  wit :  car- 
diac or  nephritic ;  the  most  common  factor  in  its  production  is  ?nechani- 
cal  obstruction  of  the  portal  system,  from  cirrhosis  of  the  liver,  tumors, 
diseases  of  the  heart  or  lungs. 

Pathological  Anatomy.  The  quantity  of  fluid  in  the  perito- 
neal sac  ranges  from  a  few  ounces  to  many  gallons.  It  is  generally 
of  a  straw  color,  or  at  times  greenish,  and  is  transparent,  having  an 
alkaline  reaction.     When  blood  is  present  in  any  great  quantity,  it 

9 


106  PRACTICE   OF   MEDICINE. 

points  to  cancer  as  a  cause.    The  peritoneum  betomes  cloudy,  sodden, 
and  thickened,  from  long  contact  with  the  fluid. 

Symptoms.  The  onset  is  insidious,  and  considerable  swelling 
of  the  abdo/nen  occurs  before  the  disease  attracts  attention.  Constipa- 
tion, from  pressure  of  the  fluid  on  the  sigmoid  flexure.  Scanty  t^ritte, 
from  pressure  on  the  renal  vessels.  Embarrassed  respirati07i  and  car- 
diac action,  from  pressure  on  the  diaphragm  upward.  The  iwtbilicus 
is  forced  outward. 

Physical  signs ;  on  palpatioti,  2i  peculiar  wave-like  impulse  is  im- 
parted to  the  hand  laying  on  the  side  of  the  abdomen,  while  gently 
tapping  the  opposite  side. 

Percussion  ;  patient  erect,  the  fluid  distends  the  lower  abdominal 
region,  with  dullness  over  the  site  of  the  fluid  and  a  tyynpanitic  note 
above  ;  if  the  patient  turns  on  his  side  the  fluid  changes,  and  dullness 
over  the  fluid,  tympanitic  over  the  distended  intestines. 

Diagnosis.  Ovarian  tumors  differ  from  ascites  in  the  history, 
in  that  the  enlargement  is  limited  to  the  iliac  fossa,  instead  of  a  uni- 
form abdominal  enlargement,  not  changing  its  position  when  the 
patient  changes  posture,  and  by  the  detection  of  a  tumor  by  conjoined 
manipulation  through  vagina,  or  by  rectal  exploration. 

Pregnancy  differs  from  ascites  in  the  character  of  the  enlargement, 
the  history,  absence  of  menses,  increase  of  mammse,  change  in  the 
neck  of  the  uterus,  absence  of  fluctuation,  and  the  presence  of  the 
sounds  of  the  foetal  heart. 

Diste7ition  of  the  bladder  has  been  mistaken  for  ascites ;  the  points 
of  distinction  are,  in  the  former  the  history,  presence  of  tenderness 
over  the  bladder,  rounded  outline  of  the  percussion  dullness,  and  the 
relief  afforded  by  the  catheter. 

Chronic  peritonitis  is  differentiated  by  the  history,  pain,  tenderness, 
more  or  less  vomiting,  thickened  abdominal  walls,  and  its  generally 
being  associated  with  tubercle  or  cancer. 

Chronic  tympanites  presents  the  enlarged  abdomeri,  but  lacks  the 
history,  the  dullness  and  the  fluctuation,  giving  instead  a  tense  abdo- 
men and  a  universal  tympanitic  note. 

Prognosis.  Influenced  by  the  causes  producing  it.  Idiopathic 
ascites,  which  is  most  rare,  terminates  in  health  within  a  few  weeks. 
\^  peritoneal,  generally  favorable.  If  from  organic  disease,  most 
unfavorable,  for  while  the  [dropsy  may  be  removed,  it  as  rapidly 
returns. 


DISEASES   OF  THE   BILIARY   PASSAGES.  107 

Treatment.  The  first  indication  is  to  treat  the  cause  of  the  ascites 
and  the  second  to  remove  the  fluid. 

Three  modes  of  removing  the  fluid  present  themselves,  to  wit  '.first, 
by  hydragogue  cathartics,  second ,  d\\irQt\cs,  and  third,  tapping.  The 
first  and  second  modes  may  be  combined,  as  follows  : — 

R.     Pulv.  jalapse  comp., 5J-ij- 

In  water,  an  hour  before  breakfast ; 

And — R  .      Potassii  acetat., gr.  x-xx-xl 

Tinct.  scillae, 5  ss 

Infus.  digitalis, f^iss.  M. 

Every  six  hours. 

Or  instead  use  the  following  : — 

1^  .     Hydrargyri  chlor.  mite, gr.  iij 

Ext,  opii, gr.  -^-^.  M. 

Et  ft.  pil. 

SiG. — One  every  three  or  four  hours. 

If  these  fail,  as  they  certainly  will  after  a  time,  the  embarrassed 
respiration  and  cardiac  action  will  call  for  tapping,  which  may  be 
done  with  the  trocar,  or  better  still,  the  aspirator. 


DISEASES  OF  THE  BILIARY  PASSAGES. 


CATARRHAL  JAUNDICE. 

Synonyms.     Catarrh  of  the  bile  ducts  ;  icterus. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  bile  ducts  and  of  the  duodenum  ;  characterized  by 
gastro-intestinal  derangement,  yellowness,  itching  of  the  skin,  fever- 
ishness  and  mental  depression. 

Causes.  Excesses  in  eating  and  drinking;  a  debauch  ;  malaria; 
climatic,  as  cool  nights  succeeding  warm  days. 

Pathological  Anatomy.  The  mucous  membrane  of  one  or 
more  of  the  bile  ducts  or  of  the  duodenum  becomes  hyperaemic, 
swollen  and  thickened,  from  an  efl"usion  of  serum  into  the  submucous 


lOS  PRACTICE   OF   MEDICINE. 

tissue ;  the  result  of  this  condition  is  the  closure  of  the  biliary- 
passages,  thereby  impeding  the  outward  flow  of  bile.  The  bile  in  the 
hepatic  ducts  being  retained  by  the  obstruction,  the  result  is  a  stain- 
ing of  the  liver  substance  and  an  absorption  of  bile,  and  its  appear- 
ance in  the  blood. 

Symptoms.  Begins  by  epigastric  distress,  coated  tongue,  impaired 
appetite,  nausea,  with,  perhaps,  vomiting  and  loose?iess  of  the  bowels 
and  slight feverishness,  the  phenomena  of  a  gastro-intestinal  catarrh. 
In  from  three  to  five  days  the  eyes  become  yellow,  and  jaundice 
gradually  appears  over  the  whole  body  ;  the  feverishness  disappears, 
the  skin  becomes  harsh,  dry  and  itchy,  the  bowels  constipated,  the 
stools  whitish  or  clay-colored,  accompanied  with  much  Jiatus  and 
colicky  paifis;  the  uriyie  heavy  and  dark,  loaded  with  urates  and  con- 
taining biliary  elements. 

A  few  drops  of  the  urine  placed  on  a  whitish  surface,  and  a  drop  or 
two  of  nitric  acid  made  to  flow  against  it,  will  exhibit  the  following 
''play  of  colors  ;  "  a  greenish  tint,  from  the  conversion  of  bilirubin 
into  biliverdin,  quickly  followed  by  blue,  violet,  red,  and  yellow,  or 
brown. 

When  the  jaundice  is  complete,  the  surface  is  cold,  the  heart's 
action  slow,  the  mind  torpid  and  greatly  depressed,  and  pain  or  ten- 
derness on  pressure  over  the  hepatic  region. 

Duration.  In  from  three  to  five  days  after  the  jaundice  appears, 
the  symptoms  subside,  save  the  torpid  bowels,  depression  and  discol- 
ored skin,  which  slowly  disappear,  often  requiring  a  week  or  two. 

Diagnosis.  After  the  appearance  of  the  jaundice,  mistakes  are 
impossible. 

The  numerous  diseases  of  which  jaundice  is  a  symptom  will  be 
differentiated  when  treating  of  them. 

Prognosis.  Always  favorable ;  if  the  attacks  are  of  frequent 
occurrence,  however,  they  are  apt  to  lead  to  organic  hepatic  changes. 

Treatment.  At  the  onset,  quinina,  gr,  x,  morning  and  night, 
may  modify  the  disease,  but  as  soon  as  the  diagnosis  is  established 
the  indications  are  for  diaphoretics,  diuretics  2ir\d  purgatives. 

For  diaphoresis,  the  warm  bath,  to  which  potassii  carbonas,  5J, 
may  be  added,  morning  and  night. 

For  diuresis,  potassii  bitartras  lemo7iade,  every  four  hours. 

Y ox  purgatives,  c\\hQr  sodii  Pyrop ho s.,  3j-iji  every  four  hours,  well 
diluted,  ammonii  murias,  gr.  xv-xx,  every   five  hours,  well  diluted, 


DISEASES   OF  THE   BILIARY   PASSAGES.  109 

magnesii  sulphas,  gr.  xx,  every  couple  of  hours,  or  hydrargyri 
chloridi  mite ,  gr.  ^,  every  hour  until  free  purgation. 

A  special  plan,  which  is  said  to  be  effective,  is  with  "  enemata  of 
cold  water.  By  means  of  an  irrigating  apparatus  the  large  intestine 
is  well  distended  with  water  once  a  day  for  several  days.  The  first 
enema  has  a  temperature  of  60°  F.,  and  subsequent  injections  are  a 
little  warmer.  The  increased  peristalsis  of  the  bowels  and  the  reflex 
contractions  of  the  gall  bladder  dislodge  the  mucous  lining  ob- 
structing the  gall  ducts.  When  the  bile  flows  into  the  intestine,  diges- 
tion is  resumed  and  the  catarrhal  inflammation  subsides."  Other 
remedies  maybe  conjoined  with  the  irrigation  method. 

Restricted  diet,  avoiding  all  starchy,  fatty  or  saccharine  articles, 
milk  being  the  most  suitable  article  of  diet. 

For  convalescence — 

Ut .     Acid,  riitro-hydrochlorici  dil., gr.  v-x 

Elix.  taraxaci  comp  , 3J-ij-  M. 

Before  meals. 

BILIARY  CALCULI. 

Synonyms.     Hepatic  calculi ;  gall  stones  ;  hepatic  colic. 

Definition.  Concretions  originating  in  the  gall  bladder,  or  biliary 
ducts,  derived  partly  or  entirely  from  the  constituents  of  the  bile. 
Their  presence  is  generally  unrecognized  until  one  or  more  attempts 
to  pass  along  the  ducts,  when  an  attack  of  hepatic  colic  is  produced. 

Causes.  Gall  stones  result  from  the  precipitation  of  the  crystal- 
lizable  cholesterine,  and  its  combination  with  inspissated  mucus  in 
the  gall  bladder  or  ducts. 

A  disease  of  middle  life,  and  more  frequent  in  the  obese,  and  in 
women. 

Gall  stones  are  said  to  be  common  in  carcinoma  of  the  stomach  or 
liver. 

Pathological  Anatomy.  Cholesterine  is  the  chief  constituent 
of  biliary  calculi.  Commonly  several  stones  exist,  and  rarely  one ; 
as  many  as  six  hundred  are  recorded.  They  are  generally  found  in 
the  gall  bladder  or  cystic  duct,  rarely  in  the  liver  or  hepatic  duct. 

Symptoms.  Hepatic  colic  begins  suddenly,  at  the  moment  a 
gall  stone  passes  from  the  gall  bladder  into  the  cyst  duct. 

The  patient  is  seized  with  a  piercing,  agonizing  pain  in  the  region 
of  the  gall  bladder,  and  spreading  over  the  abdomen,  right  chest  and 


ILO  PRACTICE   OE   MEDICINE. 

shoulder ;  the  abdominal  muscles  are  crainped  and  tender ;  there  is 
7iaiisea  and  vomitmg,  a  small,  feeble  pulse,  cool  skin,  pale,  distorted, 
anxious  face,  with,  may  be,  fainting,  spasmodic  trembling,  chills,  or 
convulsions. 

The  paroxysm  continues  from  an  hour  or  two  to  several  days,  with 
remissions,  but  entire  relief  is  not  afforded  until  the  stone  reaches  the 
duodenum,  when  the  pain  suddenly  ceases. 

faundice  usually  follows  the  paroxysm  of  pain.  When  the  calculi 
reaches  the  intestines,  the  pain,  nausea  and  vomiting  cease,  the  appe- 
tite returns,  and  the  jaundice  soon  disappears. 

Should  the  calculi  become  impacted,  ulcerative  perforation  and 
consQ(\\itn\.  peritonitis  follow,  the  calculi  discharging  by  the  intestine, 
stomach,  or  through  the  abdominal  walls. 

Diagnosis.  The  malady  should  not  be  mistaken  if  severe  pai7i, 
diverging  from  the  hepatic  region,  and  nausea  and  vomitiJig  are 
present,  suddenly  terminating,  and  followed  by  slight  Jau?idice. 

Prognosis.  Usual  termination  is  in  health.  The  prognosis  be- 
coming more  unfavorable  if  ulcerative  perforation  result. 

Treatment.  For  the  colic,  hypodermic  injections  of  morphina, 
gr.  Ye-yi-yi,  combined  with  atropina,  gr.  y^^,  and  warm  fomenta- 
tions over  the  hepatic  region,  are  indicated. 

Prof.  Bartholow  strongly  urges  the  following  prophylactic  treat- 
ment :  Carefully  regulated  diet,  abstinence  from  all  fatty  and  sac- 
charine substances,  daily  exercise,  stoppage  of  all  excesses,  and  the 
long  use  oi  sodii  pkosphas,  Z],  before  meals,  well  diluted,  to  which 
may  be  added,  if  gastro -intestinal  catarrh  be  present,  sodii  arsenias, 
gr.  ^^^,  or  aurii  et  sodii  chloridum,  gr.  -^^,  together  with  either  Vichy  or 
Saratoga  Vichy  water. 


DISEASES  OF  THE  LIVER. 


CONGESTION  OF  THE  LIVER. 

Synonyms.     Torpid  liver ;  biliousness. 

Definition.  An  abnormal  fullness  of  the  vessels  of  the  liver, 
with  consequent  enlargement  of  that  organ  ;  it  is  termed  active 
when   arterial ;   passive   when    venous.     The   condition    is    charac- 


DISEASES  OF  THE   LIVER.  Ill 

terized  by  torpidity  of  the  digestive  and  mental  functions,  and  slight 
jaundice. 

Causes.  Active  congestion ;  heat,  atmospherical  or  artificial  ; 
habitual  constipation  ;  malaria  ;  excess  in  eating  and  drinking  ;  alco- 
holic or  malt  liquor.  In  females,  an  arrested  menstrual  epoch  may 
give  rise  to  an  attack. 

Passive  congestion  ;  cardiac  and  pulmonary  diseases. 

Pathological  Anatomy.  The  liver  is  enlarged  in  all  directions, 
and  is  abnormally  full  of  blood.  Cases  due  to  obstructive  diseases 
of  the  heart  or  lungs  present  the  so-called  "  nutmeg  liver,"  to  wit: 
"  At  the  centre  of  each  lobule  the  dilated  radicle  of  the  hepatic  vein, 
enlarged  and  congested,  may  be  discerned,  while  the  neighboring 
parts  of  the  lobule  are  pale,"  the  radicles  of  the  portal  vein  containing 
less  blood. 

Long-continued  congestion  establishes  atrophic  degeneration  of  the 
organ ;  the  decrease  in  size  is  confounded  with  the  condition  of  cir- 
rhosis, but  the  "  atrophic  liver  "  is  smooth,  while  the  "  cirrhotic  liver  " 
is  nodulated. 

Symptoms.  Active  congestion ;  following  cause,  rapidly  pro- 
duced malaise,  aching  of  limbs,  evening  feveriskness,  headache, 
depression  of  spirits,  yellowish  tongue,  disgust  for  food,  nausea,  and, 
may  be,  vomiting,  constipation,  scanty,  high-colored  uri7ie,  with  a 
feeling  oi  fullness,  weight  and  soreness  in  the  hepatic  region,  with 
dull  pain  extending  to  the  right  shoulder,  and  '^\<^t  jaundice,  the  eye 
yellow,  and  the  complexion  muddy.     Duration  about  a  week. 

Passive  congestion ;  onset  gradual,  with  a  feeling  of  weight  and 
fullness  in  the  hepatic  region,  slight  jaundice,  and  symptoms  of  gas- 
tro-intestinal  catarrh. 

On  percussion  the  hepatic  dullness  is  increased  in  all  directions. 

Diagnosis.  Acute  congestion  is  continually  confounded  with 
catarrhal  jaundice ;  the  latter  begins  with  marked  gastro-intestinal 
symptoms  and  distinct  jaundice  ;  in  the  former  these  are  less  marked. 

Obstructive  congestion  is  diagnosticated  by  the  clinical  history. 

Atrophic  or  nutmeg  liver  will  be  differentiated  from  cirrhotic  liver 
when  speaking  of  the  latter. 

Prognosis.  Active  congestioji  favorable,  unless  repeated  attacks 
occur,  rapidly  succeeding  each  other,  when  "  atrophic  degeneration  " 
results. 

Passive  congestion  controlled  entirely  by  the  cause. 


112  PRACTICE   OF   MEDICINE. 

Treatment.     Attacks  due  to  excess  in  eating  and  drijiking — 

R.     Sodii  bicarb., gr.  v 

Pulv.  ipecac  ;  '    * gr.  ss 

Hydrargyri  chlor.  mit., gr.  iij-v, 

repeated,  or  sodii phospJiaiis,  Z],  every  four  hours  until  free  catharsis, 
or  small  doses  of  hydrargyri  chloridi  mite,  with  sodii  bicarbotias 
repeated  several  times,  followed  with  saline,  followed  by — 

R  .     Acidi  nitro  hydrochlorici  dil., Tt\^viiss 

Elix.  taraxaci  comp., ^ij. 

Before  meals,  and  a  milk  diet. 

Attacks  due  to  jnalaria  ;  the  above  purgative  followed  by  qtcinincE 
suiph.,  gr.  iv,  every  four  hours. 

Attacks  occurring  with  cardiac  or  pulmonary  diseases  must  be 
managed  by  treating  the  cause. 

The  tendency  to  constipation  must  be  overcome  by  the  saline  lax- 
ative waters,  to  wit :  Congress  or  Hathorn,  Pullna  or  Friedrichshall,  or 
sodii pJiosphas,  3j-'ji  three  or  four  times  daily,  well  diluted. 

Locally,  in  acute  attacks,  hot  cloths  or  sinapisms  are  of  benefit. 

In  chronic  cases  benefit  follows  elix.  quinines,  ferri  et  strychnince, 
5j,  three  times  a  day,  and  great  comfort  and  support  is  given  by  the 
use  of  the  '''hydropathic  belt,''  which  is  made  of  stout  muslin,  shaped 
to  the  abdomen,  with  cross  pieces  of  tape  on  the  inner  side,  which 
keeps  next  to  the  skin  a  fold  of  cloth  wrung  out  of  cold  water,  and  a 
piece  of  waterproof  cloth  or  oiled  silk,  to  prevent  evaporation. 

In  persons  who  seem  to  have  a  predisposition  to  attacks  of  con- 
gestion of  the  liver  upon  the  slightest  exposure  to  any  of  the  various 
exciting  causes,  the  habits  and  diet  must  be  regulated,  to  which  must 
be  added  a  course  of  alkaline  waters  and  reg^ulated  exercise. 


ABSCESS  OF  THE  LIVER. 

Synonyms.  Parenchymatous  hepatitis  ;  acute  hepatitis ;  sup- 
purative hepatitis. 

Definition.  A  diffused  or  circumscribed  inflammation  of  the 
hepatic  cells,  resulting  in  suppuration,  the  abscesses  being  sometimes 
single,  at  times  double;  characterized  by  irregular  febrile  attacks, 
hepatic  tenderness  and  symptoms  of  deranged  gastro-intestinal  and 
hepatic  functions. 


DISEASES   OF  THE   LIVER.  113 

Causes.  The  result  of  the  absorption  of  putrid  material  by  the 
portal  radicles  in  dysentery  ;  ulcers  of  the  stomach ;  malaria ;  blows 
and  injuries;  heat;  pyaemia. 

Pathological  Anatomy.  Hypersemia,  swelling,  effusion  of 
lymph,  degeneration  and  softening  of  the  hepatic  cells  ;  suppuration, 
beginning  in  points  in  the  lobules  and  coalescing.  The  abscess  walls 
consist  of  the  liver  structure,  more  or  less  changed. 

The  abscess  may  advance  toward  the  surface  of  the  liver,  bursting 
into  the  peritoneum,  intestines,  stomach,  gall  bladder,  hepatic  duct 
or  vein,  or  into  the  pleura  or  lungs,  or  externally  through  the 
abdominal  walls;  after  the  discharge  of  pus,  cicatrization  occurs, 
or  the  pus  may  be  absorbed,  the  tissues  around  forming  a  dense 
cicatrix. 

Symptonis,  Very  obscure.  Fever  simulating  markedly  inter- 
mittent or  remittent  fevers ;  disorders  of  the  gastro-intestinal  canal, 
with  obstinate  vomiting,  debility,  and  great  irritability  of  the  nervotis 
system,  melancholia,  slight  jaundice,  constipation,  the  stools  light  col- 
ored, and  if  of  long  duration,  typhoid  symptoms. 

Locally,  if  the  abscess  is  near  the  surface,  ^r^;;/z«^;z^^  of  the  hepatic 
region,  throbbing,  limited  tenderness,  and  if  it  tends  to  the  surface, 
redness,  oedema  and  fluctuation.  The  abscess  may  burst  into  the 
intestines,  stomach,  lungs,  or  pleura,  the  symptoms  of  which  will  be 
pronounced. 

Diagnosis.  Hepatic  abscess  may  be  confounded  with  hydatids 
of  the  liver,  hepatic  or  gastric  cancer,  abscess  of  the  abdominal  walls, 
and  purulent  effusion  in  the  right  pleural  cavity. 

The  differentiation  is  most  difficult,  but  great  aid  is  obtained  from 
the  use  of  the  aspirator. 

Prognosis.  Unfavorable.  Recoveries,  however,  do  occur.  If 
the  abscess  bursts  into  the  lungs,  bowels,  or  externally  through  the 
abdominal  wall,  the  case  is  more  favorable. 

Treatment.  Symptomatic,  and  when  pus  is  present,  the  use  of 
the  aspirator  to  remove  it,  and  sustaining  treatment,  to  wit :  quitiina, 
ferricm,  alcohol,  and  oleum  morrhuce. 


114  PRACTICE   OF   MEDICINE. 

ACUTE  YELLOW  ATROPHY. 

S3nionyms.  General  parenchymatous  hepatitis  ;  malignant  jaun- 
dice ;  hemorrhagic  icterus. 

Definition.  An  acute,  diffused  or  general  inflammation  of  the 
hepatic  cells,  resulting  in  their  complete  disintegration  ;  characterized 
by  diminution  in  the  size  of  the  liver,  deep  jaundice,  and  profound 
disturbance  of  the  nervous  system  ;  terminating  in  death,  usually, 
within  one  week. 

Causes.  Unsettled.  It  occurs  frequently  in  young  pregnant 
women,  from  the  third  to  the  sixth  month  of  pregnancy.  Other  causes 
are  venereal  excesses ;  syphilis ;  action  of  phosphorus,  arsenic  or 
antimony. 

Pathological  Anatomy.  Begins  with  hyperaemia  of  the  he- 
patic cells,  with  a  grayish  exudation  between  the  lobules,  followed  by 
softening,  dull  yellow  color,  and  disappearance  of  the  cells,  fat  glob- 
ules taking  their  place.  The  liver  is  reduced  in  size  and  in  weight. 
The  peritoneum  covering  the  liver  is  thrown  into  folds.  The  spleen 
is  enlarged.  The  kidneys  undergo  degeneration.  The  blood  con- 
tains a  large  amount  of  urea  and  considerable  leucin.  The  urine  is 
loaded  with  bile  pigment,  and  contains  albumin. 

Symptoms.  Prodromic  period ;  begins  as  a  gasiro-intestinal 
catarrh,  coated  tongue,  nausea,  vomiting,  tenderness  over  the  epigas- 
trium, headache,  quickened  pulse,  slight  fever  and  s\\^\.  jaundice. 

Icteric  period ;  jaundice  deepens,  pulse  slow,  headache  increases, 
and  great  and  obstinate  sleeplessness. 

To xcemic  period ;  fever,  rapid  pulse,  more  cora^lQiejatmdice,  pain, 
nausea,  vomiting  of  blackish,  grujnous  blood,  or  "  coffee  grounds," 
tarry  stools,  ecchymotic  patches,  convulsio7ts  or  epileptiform  attacks, 
coma,  insensibility,  death. 

Percussion  shows  markedly  decreased  hepatic  dullness. 

Duration.     Short.    After  appearance  of  jaundice,  about  six  days. 

Prognosis.     Unfavorable. 

Treatment.  Entirely  symptomatic.  Prof.  Bartholow  "  advises 
the  trial  of  very  small  doses  of  phosphorus,  as  early  as  possible,  as 
this  remedy  affects  the  organ  specifically,  and  an  action  of  antagon- 
ism may  be  discovered  between  them." 


DISEASES   OF  THE   LIVER.  115 

SCLEROSIS  OF  THE  LIVER. 

Synonyms.  Intestinal  hepatitis;  cirrhosis  of  the  liver ;  hob- 
nailed liver  ;  gin-drinkers'  liver. 

Definition.  An  inflammation  of  the  intervening  connective 
tissue  of  the  liver,  chronic  in  its  progress,  resulting  in  an  induration 
or  hardening  of  the  organ  and  an  atrophy  of  the  secreting  cells  ; 
characterized  by  gastro-intestinal  catarrh,  emaciation,  slight  jaundice 
and  ascites. 

Causes.  The  prolonged  use  of  alcohohc  stimulants,  gin,  whisky, 
beer,  or  porter  ;  syphilis. 

Pathological  Anatomy.  First  stage ;  hyperaemia  of  the  con- 
nective tissue  (Glisson's  capsule)  of  the  liver,  and  the  development 
of  brownish-red  connective-tissue  elements,  whereby  the  organ  is 
increased  in  size  and  density ;  this  increase  of  the  connective-tissue 
presses  upon  the  hepatic  cells,  causing  them  to  undergo  fatty  degene- 
ration. 

Second  stage  ;  the  newly  formed,  imperfectly  developed  connective 
tissue  contracts,  causing  decrease  in  the  size  and  induration  of  the 
organ,  its  surface  being  nodulated.  The  hepatic  and  portal  circula- 
tion is  obstructed,  from  obliteration  of  their  radicles. 

The  hepatic  peritoneum  is  thickened  and  opaque,  and  adhesions 
are  formed  to  the  diaphragm,  gall-bladder  and  stomach. 

Cases  occur  in  which  the  sclerosis  takes  place  while  the  organ  con- 
tinues enlarged  ;  these  cases  are  known  as  hypertrophic  sclerosis. 

Symptoms.  No  characteristic  symptoms  of  the  early  stage  of 
the  affection.  Persistent  gastro-intestinal  catarrh,  with  attacks  of 
jaundice,  in  a  drinking  man,  are  suspicious.  Symptoms  of  the  second 
stage  are,  abdominal  dropsy,  ejtlargement  of  the  superficial  abdominal 
veins,  dyspepsia,  localized  peritoneal  pain,  hemorrhages  from  the 
stojnach  or  intestines,  muddy  or  slightly  jaundiced  skin  and  decided 
emaciation;  the  enormously  distended  abdomen  with  thin  legs  are 
characteristic  of  sclerosis  of  the  liver. 

Diagnosis.  Atrophy  of  the  liver,  or  the  nutmeg  liver,  is  almost 
always  confounded  with  sclerosis;  the  former  occurs  most  commonly 
with  obstructive  diseases  of  the  heart  and  lungs,  and  the  surface  of  the 
organ  is  not  nodulated,  nor  is  there  a  history  of  alcoholism. 

Cancer  a7td  tubercle  of  the  peritoneum  have  many  symptoms  akin 
to  sclerosis.  The  points  of  differentiation  are,  great  tenderness  over 
abdomen,  rapidly  developed  ascites,  rapid  dechne  in  strength  and 


116  PRACTICE   OF   MEDICINE. 

flesh,  absence  of  jaundice,  absence  of  long-continued  dyspepsia,  ab- 
sence of  hepatic  changes  on  percussion,  and  the  presence  of  tubercle 
or  cancer  deposits  in  other  organs. 

Prognosis.  Terminates  in  death.  Average  duration  after  ap- 
pearance of  the  dropsy,  one  year. 

Treatment.  For  the  changes  in  the  hepatic  structure,  little,  if 
anything  can  be  done;  the  following  are  some  of  the  remedies  recom- 
mended, to  wit,  hydrargyri  chloridiim  corrosivinn,  gr.  ^V"T(J>  three 
times  a  day  ;  hydrargyri  chloridtiin  mite,  gr.  y^^,  three  times  a  day  ; 
a2irii  et  sodii  chloridtini,  gr.  -^q,  after  meals;  sodii  phosphas,  3ss-j, 
after  meals  ;  potassii  iodidum,  after  meals. 

The  diet  must  be  regulated,  milk  being  the  most  suitable,  and 
avoiding  fatty  and  saccharine  foods. 

The  abdominal  dropsy  may  be  temporarily  benefited  by  purgatives 
and  diuretics,  but  sooner  or  later  tapping  becomes  imperative. 

AMYLOID  LIVER. 

Sjnaonyms.  Waxy  liver ;  lardaceous  liver ;  scrofulous  liver ; 
albuminous  liver. 

Definition.  A  peculiar  infiltration  into,  or  a  degeneration  of,  the 
structure  of  the  liver,  from  the  deposit  of  an  albuminoid  material, 
which  has  been  termed  amyloid,  from  a  superficial  resemblance  to 
starch  granules. 

Causes.  The  chief  cause  is  prolonged  suppuration,  especially  of 
the  bones  ;  coxalgia  ;  syphilis,  cancer. 

Pathological  Anatomy.  The  liver  is  uniformly  enlarged.  It 
presents  a  pale,  glistening,  translucent  appearance,  and  has  a  doughy 
consistency.  On  section,  the  surface  is  homogeneous,  is  anaemic  and 
whitish.  The  deposit  begins  in  the  arterioles  and  capillaries,  finally 
closing  them. 

The  reaction  with  iodine  and  sulphuric  acid  affords  a  certain  test  of 
the  amyloid  or  albuminoid  deposits.  After  further  cleansing,  brush 
over  the  parts  a  solution  of  iodine  with  iodide  of  potassium  in  water, 
when  they  will  assume  a  mahogany  color,  and  if  diluted  sulphuric 
acid  be  added,  a  violet  or  bluish  tint  is  produced. 

A  pretty  reaction  is  to  take  a  one  per  cent,  solution  of  anilin  violet, 
which  strikes  a  red  or  pink  color  with  the  amyloid  or  albuminoid 
material,  while  the  unaltered  tissues  are  stained  blue,  thus  showing  a 
beautiful  contrast. 


DISEASES   OF  THE   LIVER.  117 

The  amyloid  change  involves  the  spleen,  kidney,  intestines,  and 
their  organs. 

Symptoms.  Nothing  characteristic.  Hepatic  dullness  increased, 
with  prominence  over  the  liver.  Absence  of  pain.  Splenic  dullness 
increased.  Emaciation  and  anaemia.  Urine  increased  in  amount, 
pale,  and  containing  some  albumin,  due  to  amyloid  changes  in  the 
kidneys.  Disorders  of  digestion,  with  diarrhoea,  due  to  amyloid 
changes  in  the  intestines.     Jaundice  is  rare.     Ascites  seldom  occurs. 

Prognosis.  Unfavorable.  The  progress  is  rapid  or  slow,  depend- 
ing upon  the  cause. 

Treatment.  No  specific.  Prof.  Da  Costa  recommends  ammonii 
murias,  gr.  x-xx,  three  times  daily,  for  several  weeks,  then  change 
for  same  length  of  time  to  syriipiis  ferri  iodidum,  beginning  with  rr^x 
gradually  increased  to  f^j  after  meals,  then  to  the  former  again,  and 
so  on,  for  months.  Symptomatic,  with  prolonged  use  oi  ferrimi,  syr. 
calcii  lactophosphas  and  oleum  morrhuce. 

HEPATIC  CANCER. 

Synonym.     Carcinoma  of  the  liver. 

Definition.  A  peculiar  morbid  growth,  progressively  destroying 
the  hepatic  tissue;  characterized  by  disorders  of  digestion,  anaemia, 
emaciation,  jaundice  and  ascites,  and  terminating  in  the  death  of  the 
patient. 

Causes.  Hereditary,  when  it  is  termed  primary  cancer  ;  from 
extension  from  other  organs,  when  it  is  termed  secondary  cancer.  It 
is  a  disease  of  advanced  life,  from  forty  to  sixty  years. 

Pathological  Anatomy.  The  most  common  variety  of  cancer 
of  the  liver  is  a  compound  of  the  medullary  and  scirrhus. 

The  cancer  cells  develop  from  the  interlobular  connective  tissue, • 
and  as  they  grow  the  hepatic  cells  atrophy,  the  result  of  the  pressure 
of  the  new  growth.  The  branches  of  the  hepatic  artery  enlarge 
and  permeate  the  growth,  while  the  branches  of  the  portal  vein 
are  compressed  and  atrophied,  thereby  blocking  up  the  portal  cir- 
culation. 

The  cancer  may  develop  in  nodules  or  masses,  or  may  be  diffused  ; 
the  nodules  vary  in  size,  and  those  on  the  surface  are  rounded,  with 
a  central  umbilication.  The  peritoneum  is  adherent,  cloudy  and 
thickened. 

Symptoms.     The  development  of  hepatic  cancer  is  preceded  by 


118  PRACTICE   OF   MEDICINE. 

a  history  of  dyspepsia,  flatulency  and  constipation.  The  uneasiness, 
'Weight  and/az>z,  increased  by  pressure,  are  noticed  \  jaundice,  ascites, 
occasional  intestinal  hemorrhages,  emaciatiofi,  feebleness,  ancemia, 
cold,  dry,  harsh  ski?t,  pinched  featitres,  with  dejected,  worn  expressiojt. 
Fever  never  occurs.  The  hepatic  dullness  is  increased,  with  pains  on 
palpation,  and  the  liver  is  indurated,  irregular  and  nodulated. 

The  duration  is  less  than  a  year  from  the  time  the  disease  is 
recognized. 

Diagnosis.  The  points  of  differentiation  are  the  age,  cachexia, 
pain  and  tenderness,  enlarged  liver  with  hard  nodules,  and  rapid 
progress. 

Prognosis.     Always  terminates  in  death. 

Treatment.  Early,  symptomatic.  Sooner  or  later  (?^Z2^;«  must  be 
used,  to  relieve  the  terrible  and  persistent  pain. 


DISEASES  OF  THE  KIDNEYS. 


THE  URINE. 

The  normal  quantity  of  urine  varies  from  twenty  to  fifty  ounces 
in  the  twenty-four  hours ;  it  is  decreased  by  free  perspiration  and 
increased  by  chilling  of  the  skin. 

The  normal  color  is  light  amber,  due  to  urobilin  ;  the  color  deepens 
if  the  quantity  voided  be  decreased,  and  vice  versa. 

The  7iormal  reaction  is  slightly  acid,  due  to  the  acid  sodic  phos- 
phate, uric  and  hippuric  acids.  After  meals  it  may  be  neutral  or 
even  alkaline. 

The  normal  specific  gravity  varies  from  1.008  to  1.020;  it  is  low 
when  an  increased  quantity  is  passed  and  high  when  the  quantity  is 
diminished. 

The  most  important  organic  and  inorganic  solid  constituents  held 
in  solution  are,  urea  (the  index  of  nitrogenous  excretion),  from  308 
to  617  grains  daily  ;  uric  acid,  from  6  to  12  grains  ;  urates  of  sodium, 
am.monium,  potassium,  calcium  and  magnesium,  from  9  to  14  grains; 
phosphates  of  sodium,  etc.,  from  12  to  45  grains,  and  chlorides  of 
sodium^  etc.,  from  154  to  247  grains  daily. 


DISEASES    OF   THE   KIDNEYS. 


119 


I.  Quantitative  test 
for  urea,  by  hypobro- 
mite  of  sodium(Davy's 
Method). 


II.  Tests  for  urates 
and  uric  acid  by  nitric  "! 
acid. 


III.  Quantitative  test 
for  uric  acid  by  nitric 
acid. 


Fill  a  graduated  glass  tube  one-third  full 
of  mercury,  and  add  one-half  drachm  of  the 
24  hours'  urine  ;  then  fill  the  tube  evenly 
full  with  a  saturated  solution  of  hypobromiie 
of  sodium,  and  close  it  immediately  with  the 
thumb  ;  invert  the  tube  and  place  its  open 
end  beneath  a  sat.  sol.  oi  chloride  of  sodium  ; 
the  mercury  flows  out  and  is  replaced  by  the 
solution  of  salt;  nitrogen  gas  is  disengaged 
from  the  urea  in  the  upper  part  of  the  tube. 

Each  citbic  inch  of  gas  represents  .645  gr. 
of  urea  in  the  half  drachm,  from  which  the 
amount  passed  in  24hours  may  be  calculated. 

Urine  containing  an  excess  of  urates  and 
uric  acid,  on  cooling,  precipitates  them  (viz.: 
"  brickdust  deposits  "  in  "  pot  de  chambre"). 
Neat  dissolves  them  to  a  certain  extent. 

Nitric  acid  deprives  the  soluble  neutral 
urates  of  their  bases,  and  produces,  at  first, 
a  faint,  milky  precipitate  of  amorphous  acid 
urates ;  adding  more  acid,  the  still  less  solu- 
ble red  crystals  of  uric  acid  are  deposited. 

Put  a.  small  quantity  of  nitric  acid  in  a 
test-tube,  and  pour  the  urine  carefully  down 
the  sides  of  the  tube  upon  it,  and  a  zone  of 
yellowish-red  tiric  acid  and  altered  coloring 
matter  will  form  at  their  union  ;  and  a  dense, 
milky  zone  of  acid  urates  above  this,  which, 
however,  dissolves  upon  agitation.  (See 
albumin  test.) 

To  three  ounces  of  the  24  hours'  urine 
(after  being  slightly  acidulated,  boiled  and 
filtered  while  hot)  add  07ie-tenth  as  much 
7iitric  acid ;  place  in  a  cool  place  for  24 
hours,  then  collect  the  deposit  of  uric  acid 
on  a  weighed  filter,  wash  it  thoroughly,  and 
dry  at  212°  F.  The  increased  weight  repre- 
sents the  uric  acid  in  part  excreted,  approxi- 
mately. 


120 


PRACTICE   OF   MEDICINE. 


IV.  Test  for  the 
earthy  and  alkahne 
phosphates  by  the 
magnesian  fluid. 


by  acetic  acid  and  li- 
quor iodi  comp. 


V.  Test  for  the  chlo- 
rides by  nitrate  of  sil- 
ver. 


VI.    Test  for  7nucus  \ 


VII.  Test  for  albu- 


Heat  or  /igtior potassa\ncre.2ise.%  the  cloud- 
iness caused  by  earthy  calcium  and  magne- 
sium phosphates.  Acetic  or  nitric  acid  clears 
it  by  dissolving  them. 

To  two  ounces  of  urine  add  one-third  as 
much  of  the  following  solution,  to  wit :  R- 
Magnesii  sulph.,  ammonii  chloridum  purae, 
liquor  ammonicC,  each  one  part ;  aquae  destil., 
eight  parts;  if  the  precipitate  has  a  milky, 
cloudy  appearance,  the  quantity  of  phos- 
phates is  normal ;  if  creamy,  the  phosphates 
are  in  excess. 

To  a  convenient  quantity  of  urine  add  a 
small  amount  of  nitric  acid,  to  prevent  the 
formation  of  the  phosphates  and  other  salts 
of  silver;  filter  this,  if  cloudy;  add  to  this 
one  drop  of  a  solution  of  nitrate  of  silver  (i 
part  to  8)  and  the  precipitate  of  white  cheesy 
lumps  of  chloride  of  silver  denotes  that  the 
amount  of  chlorides  is  normal ;  if,  however, 
only  a  faint  milki7iess  occurs,  the  chlorides 
are  diminished. 

Mucus  alone  is  not  visible,  but  causes 
cloudiness,  from  having  entangled  mucus  or 
pus  corpuscles,  epithelium,  granules  of  so- 
dium urate,  crystals  of  oxalate  of  lime  and 
uric  acid  in  various  amounts. 

Add  to  the  urine  a  little  acetic  acid,  or,  in 
addition,  a  few  drops  of  liquor  iodi  comp., 
when  threads  and  bands  o{  mucin  are  made 
visible.  The  addition  of  nitric  acid  dis- 
solves them. 

Slightly  acidulate  the  urine,  if  necessary, 
by  addition  of  nitric  or  acetic  acid,  and  boil ; 
this  causes  a  white  deposit  of  coagulated 
albinnin,  which  is  not  dissolved  by  nitric 
acid,  unless  the  acid  is  in  excess. 

Nitric  acid  causes  a  white  deposit  of 
coagulated  albumin,  which  is  dissolved  if  a 


DISEASES    OF   THE   KIDNEYS. 


121 


mi7i  by  heat  and  nitric 
acid. 


VIII.  Quantitative 
test  for  albumin.  Ap- 
proximately. 


IX.     Test  for  blood 
by  heat  and  nitric  acid. 


X.  Test  for  blood  by 
heat  and  caustic  pot- 
ash (Heller's). 


XI.     Test  {qx pus  by 
liquor  potassa. 


large  excess  of  acid  be  added.  A  delicate 
test  is  to  put  the  nitric  acid  in  the  tube  first, 
and  then  gradually  pour  the  urine  down  the 
side  of  the  tube  upon  it,  when  a  white  zone, 
or  ritig  of  coagulated  albumin  appears.  Pre- 
caution, see  tests  Nos.  3,  4,  9  and  11. 

Add  a  few  drops  of  7iitric  acid  to  a  pro- 
portion of  the  urine,  and  boil ;  set  this  away 
for  24  hours,  and  the  proportionate  depth  of 
the  resulting  deposit  is  the  comparative 
indication,  viz.,  X~X>  etc. 

Heat  or  nitric  acid  causes  deposit  of  albu- 
min, with  the  coloring  matter  changed  to  a 
dirty  brown. 

Heat  the  urine,  then  add  caustic  potash 
and  heat  anew\  The  phosphates  are  thus 
precipitated,  taking  with  them  the  coloring 
matter  of  the  blood,  which  imparts  a  dirty, 
yellowish-red  color  to  the  sediment,  viewed 
by  reflected  light,  and  when  seen  by  trans- 
mitted light,  gives  a  s^\^v\.^\^  blood-red 
color. 

Neither  the  coloring  matter  of  the  blood, 
nor  that  of  the  bile,  is  precipitated  with  the 
phosphates,  so  that  coloration  of  urine  which 
shows  this  reaction  cannot  be  ascribed  to 
the  presence  of  the  latter  pigments. 

When  the  quantity  of  blood  in  the  urine 
is  very  large,  it  is  of  a  dark  or  brownish-red, 
and  after  standing,  forms  a  coagulum  of 
blood  at  the  bottom  of  the  vessel. 

Caution.  Heat  or  nitric  acid  causes  co- 
agulation of  the  albumin  in  pus. 

Add  to  the  urine,  or  preferably  to  its  de- 
posit from  standing,  an  equal  volume  of 
liquor  potassa  ;  when  well  mixed,  a  viscid 
gelatinous  fluid  or  mass  is  formed,  which 
pours  like  the  white  of  an  t^z,  or  jelly. 


10 


122 


PRACTICE   OF   MEDICINE. 


XII.  Test  for  3//^  by 
"  fuming  "or  red  nitric 
acid. 


XIII.  Test  for  bile 
pigment  by  pure  hy- 
drochloric and  pure 
nitric  acids  (Heller's). 


XIV.  Test  for  sugar 
by  liquor  potassa  and 
heat  (Moore's). 


XV.  Test  for  sugar 
by  subnitrate  of  bis- 
muth, liquor  potassa 
and  heat. 


Allow  a  specimen  of  urine  and  a  few  drops 
of  red  "fuming"  nitric  acid  to  gradually 
intermingle  on  a  porcelain  dish,  and  a  "  play 
of  colors,"  ^<f^«,  bhte,  violet,  red  and  yellow 
or  broiun,  occurs,  if  biliary  coloring  matter  be 
present. 

Pour  into  a  test-tube  about  1.6  f^  of  pure 
hydrochloric  acid,  and  add  to  it,  drop  by 
drop,  just  sufficient  urine  to  distinctly  color 
it.  The  two  are  mixed.  Then  drop  down 
the  side  of  the  test-tube  pure  nitric  acid, 
which  will  "underlay  "  the  mixture  of  hydro- 
chloric acid  and  urine.  At  the  point  of 
contact  between  the  mixture  and  the  color- 
less nitric  acid  a  handsome  "  play  of  colors  " 
appears.  If  the  "underlying"  nitric  acid 
is  now  stirred  with  a  glass  rod,  the  set  of 
colors  which  were  superimposed  upon  one 
another  will  appear  alongside  of  each  other 
in  the  entire  mixture,  and  should  be  studied 
by  transmitted  light. 

If  the  hydrochloric  acid,  on  addition  of 
the  biliary  urine,  is  colored  reddish-yellow, 
the  coloring  matter  is  bilirubin  ;  if  it  is  col- 
ored ^r^^;z,  it  is  biliverdin. 

Add  to  the  urine  half  its  volume  of  liquor  po- 
tassa. ( Cautio7i.  This  ;;mj/give  a  white,  flaky 
precipitate  of  the  earthy  phosphates,  which 
should  be  removed  by  filtering.)  Now  boil ; 
this  causes,  at  first,  z.  yellow-brownish  color, 
becoming  darker  if  much  sugar  is  present, 
due  to  glucic,  and  finally  to  melassic  acid. 

Add  to  the  urine  half  its  volume  of  liqtcor 
potassa,  and  then  a  little  bismuth  subnitrate, 
shake  and  thoroughly  boil ;  the  presence  of 
sugar  reduces  the  salt  and  black  metallic 
bismuth  is  deposited,  or  if  but  little  sugar,  a 
gray  deposit  occurs. 

Caution.     Albumin  must  be  absent. 


DISEASES   OF   THE   KIDNEYS. 


123 


XVI.  Test  for  sugar 
by  a  solution  of  cupric 
sulphate,     liquor    po-  ^ 
tassa  and  heat  (Trom- 
mer's). 


XVII.  Quantitative 
test  for  sugarhy  Pavy  s 
solution,  to  wit : — 

R. 

Cupric  sulphate,  gr.    320 
Neutral  potassic 

tartrate,  .  .  gr.  640 
Caustic  potash,  .  gr.  1280 
Distilled  water,  f  ^      20 

Keep  corked. 


XVIII.  Quantitative 
test  for  sugar  by  fer- 
mentation and  the 
specific  gravity. 


Add  to  the  urine  a  few  drops  of  a  solution 
of  cupric  sulphate,  and  then  its  own  volume 
q{ liquor  potassa.  {Cauiio?i.  On  first  addi- 
tion, a  light- greenish  precipitate  occurs, 
which,  on  further  addition  of  the  reagent,  if 
sugar  or  certain  other  organic  matters  are 
dissolved,  gives  a  transparent  blue  liquid.) 
Now  boil,  and  a  yellowish  precipitate  of 
hydrated  cupric  suboxide,  occurring  at  once, 
denotes  xYio.  presejice  of  sugar. 

Caution.  Albumin  must  be  absent. 
f  Take  of  Pavy  s  solution  of  cupric  protox- 
ide, recently  prepared  (see  margin),  200 
minims  or  a  multiple  of  this  quantity,  and 
boil  in  a  porcelain  dish  ;  while  boiling,  add, 
minim  by  minim,  from  a  measured  portion 
of  the  24  hours'  urine,  and  it  gives  2.  yellow- 
ish precipitate  of  hydrated  cupric  suboxide, 
if  sugar  be  present. 

Note  carefully  the  gradual  disappearance 
of  the  bhie  color,  and  when  completed  (best 
determined  by  looking  through  the  margin 
of  the  fluid  against  the  white  porcelain  dish), 
from  the  amount  of  urine  used^  determine 
the  amount  of  sugar  passed  daily.  The 
quantity  of  urine  cofttaining  one  grain  of 
sugar  being  just  sufficient  to  reduce  the  200 
minims  of  the  copper  solution. 

Take  two  measured  specimens  from  the 
24  hours'  urine,  and  to  one  add  a  XiVX^q  yeast. 
Place  each  specimen  in  a  temperature  of  75° 
to  80°  Fah. ;  in  24  hours,  fermentation  hav- 
ing destroyed  the  sugar  in  the  one  contain- 
ing the  yeast,  the  difference  in  the  specific 
gravity  of  the  two  specimens  expresses  the 
number  of  grains  in  each  ounce  of  the  urine 
approximately. 


12.4  PRACTICE    OF   MEDICINE. 

CONGESTION  OF  THE  KIDNEYS. 

Synonyms.     Renal  hyperaemia  ;  catarrhal  nephritis. 

Definition.  An  increase  in  the  amount  of  blood  in  the  vessels 
of  the  kidneys  ;  when  arterial,  it  is  termed  active  congestion ;  when 
\^x\.o\is, passive  congestion  ;  characterized  by  pain,  frequent  desire  for 
urination,  the  amount  of  urine  scanty,  high-colored,  occasionally  con- 
taining albumin  or  blood. 

Causes.  Active;  from  cold;  irritating  substances  eliminated  by 
the  kidneys,  to  wit :  turpentine,  copaiba,  cantharides ;  during  the 
eruptive  or  continued  fevers  ;  injuries  over  the  kidneys. 

Passive ;  obstructive  diseases  of  the  heart  or  lungs,  and  pressure  of 
the  pregnant  uterus. 

Pathological  Anatomy.  The  kidneys  enlarge  and  increase 
in  weight ;  increased  redness  (the  color  being  bluish  if  passive),  with 
points  of  vascularity,  corresponding  to  the  Malpighian  bodies,  and 
occasionally  minute  ecchymoses.  The  abnormal  hyperaemia  causes 
a  catarrhal  state  of  the  ducts  of  the  pyramids,  with  shedding  of  their 
epithelium. 

If  mechanical  {^passive)  obstruction  continue  for  some  time,  increase 
of  the  connective  tissue,  with  consequent  induration  and  contraction, 
results,  or  a  form  of  chronic  Bright's  disease. 

Symptoms.  Active  variety ;  pain  over  kidneys  and  following 
the  course  of  the  ureters  into  the  testicles  and  penis,  irritable  bladder, 
almost  constant  and  pressing  desire  for  urination,  the  tiritie  scanty, 
high-colored,  and  occasionally  bloody,  with  fibrin,  casts  and  albumin  ; 
there  is,  as  a  rule,  no  pain  during  the  act  of  urination.  The  constitu- 
tional symptoms  are  headache,  slight  nausea,  vomiting  and  a  general 
feeling  of  discomfort. 

If  the  condition  persist,  inflamination  of  the  kidney  results. 

Passive ;  the  kidney  changes  are  marked  by  the  lung  or  heart 
trouble,  until  dropsy,  scanty,  high-colored,  albiuninoics  urine  is  observed. 

Prognosis.    Active  ;  if  recognized  and  properly  treated,  favorable. 

Passive,  controlled  by  the  cause,  and  if  prolonged,  terminating  in 
interstitial  nephritis. 

Treatment.  Rest  of  the  body  ;  dry  or  wet  cups  over  the  loins  ; 
dilute  the  urine  by  increasing  the  quantity  of  bland  fluids  consumed ; 
saline  purgatives;  warm  bath  or  other  mild  diaphoretics;  itifusiim 
digitalis  is  pre-eminently  the  remedy  for  congestion  of  the  kidneys ; 
if  great  irritability  of  the  bladder,  camphora,  gr.  ij-iv,  every  four  hours, 


DISEASES   OF   THE   KIDNEYS.  125 

combined  with  7norphmce  sidph.,  gr.  ^^  \,  or  the  hypodermic  injec- 
tion of  morpJiina,  gr.  ^. 

The  treatment  of  the  passive  form  resolves  itself  into  the  treatment 
of  the  cause. 

ACUTE  BRIGHT' S  DISEASE. 

Synonyms.  Acute  desquamative  nephritis  ;  acute  parenchyma- 
tous nephritis  ;  acute  tubal  nephritis. 

Definition.  An  acute  inflammation  of  the  epithelium  of  the 
uriniferous  tubules ;  characterized  by  fever,  scanty,  high-colored  or 
smoky  urine,  dropsy,  with  more  or  less  constant  nervous  phenomena, 
the  result  of  acute  uraemia. 

Causes.  The  young  more  liable  than  the  aged;  cold  and  ex- 
posure ;  scarlatina ;  persistent  use  of  irritants,  to  wit :  turpentine 
and  cantharides.  Blows  and  injuries  of  the  back  have  caused  this 
affection. 

Pathological  Anatomy.  The  kidneys  are  generally  swollen, 
engorged,  more  vascular,  and  of  a  red  color;  in  the  second  stage  the 
organ  remains  large,  irregularly  red,  especially  the  cortex;  the 
tubules  are  engorged  and  filled  with  epithelium,  blood  corpuscles  and 
fibrin.  The  capsule  is  easily  detached,  and  is  more  opaque  than 
normal. 

If  a  favorable  termination,  the  swelling  lessens,  the  vascularity 
diminishes,  the  tubules  returning  to  a  normal  condition. 

Symptoms.  Usually  begins  suddenly.  Fever,  with  nausea  and 
violent  ^.nd.  persistent  vomiting,  dull  pain  over  the  kidneys,  following 
the  ureters  ;  frequent  desire  to  urinate  ;  diarrhoea ;  s^in  harsh  and 
dry  ;  pulse  quick,  tense  and  full.  Soon  dropsy  appears,  the  eyelids 
and  face  become  puffy  and  swollen,  followed  by  general  oedema  of 
the  extremities,  scrotum  and  abdominal  walls.  If  the  attack  follow 
scarlatina  there  are  from  the  onset  much  greater  pallor  and  general 
debility. 

The  urijie  is  of  high  specific  gravity,  scanty,  smoky  (like  beef  wash- 
ings) in  color,  due  to  the  presence  of  blood.  Albuniiii  is  present  in 
large  quantities,  and  the  microscope  reveals  casts  of  the  uriniferous 
tubules,  blood  corpuscles,  uric  acid,  urates  and  oxalate  crystals  and 
epithelium. 

Duration  from  one  to  four  weeks. 

Complications.     Pericarditis,  pleuritis,  pneumonitis,  peritonitis, 


126  PRACTICE   OF   MEDICINE. 

or  acute  tircsmia,  from  retention  and  decomposition  of  urea  in  the 
blood. 

Diagnosis.  The  history,  fever,  scanty,  smoky,  albuminous  urine, 
with  dropsy  beginning  in  the  face,  should  prevent  any  error. 

Albumuuiria  may  be  confounded,  on  account  of  the  presence  of 
albumin  in  the  urine,  but  lacks  the  clinical  history,  usually  occurring 
in  the  course  of  some  constitutional  affection,  to  wit :  diphtheria, 
cholera,  yellow  fever  or  erysipelas. 

ProgTlosis.  Favorable.  Majority  of  cases  recover  under  prompt 
treatment.  Rarely  passes  into  chronic  Bright's  disease.  Urcemic 
symptoms  add  to  the  gravity  of  the  prognosis. 

Treatment.  Absolute  rest  in  bed.  Milk  diet,  or  if  much  depres- 
sion, also  weak  animal  broths  and  oysters.  Drink  freely  of  water,  but 
neither  tea,  coffee  nor  stimulants.  Counter-irritatioft  over  the  kid- 
neys by  dry  or  wet  cups  and  poultices  of  digitalis. 

For  the  dropsy,  purgation  hy  pulv.  jalapCB  conip.,  3j.  in  water, 
before  breakfast,  or  elateriiim,  gr.  ^. 

Diaphoresis,  by  warm  baths,  or  extractujn  pilocarpi  fluidum,  tt^x- 
XXX,  every  three  or  four  hoars,  or  vinum  ipecacuanhce,  gtt.  j-ij,  every 
half  hour. 

Diuresis,  by — 

R.     Potass,  acetas, gr.  x-xx 

Infus.  digital., f,^ij 

Infus.  juniperi, f  3  ij-  M. 

Every  two  or  four  hours. 

As  soon  as  the  blood  disappears  from  the  urine,  a  course  o{ferrum, 
in  the  shape  of  Bashaitis  7nixture,  until  albumin  disappears  and 
health  is  restored.  The  following  is  the  formula  of  Basham's  mix- 
ture : — 

% .     Liq.  ammon.  acetat., ^,f  ^j 

Acid,  acetic, ^iij 

Tinct.  ferri  chlcr., f  ,^  v 

Alcoholis, 5ij 

Syrup, •  f.V^ 

Aquae fjiv-  M. 

SiG.— Dose,  f^j-f  Jj. 


DISEASES   OF   THE   KIDNEYS.  127 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms.  Chronic  Bright's  disease  ;  chronic  tubal  nephritis  ; 
chronic  albuminuria;  large  white  kidney. 

Definition.  A  chronic  inflammation  of  the  cortical  and  tubular 
structure  of  the  kidneys  ;  characterized  by  albuminous  urine,  dropsy, 
increasing  anemia,  with  attacks  of  acute  urceiiiia. 

Causes.  Occasionally  follows  the  acute  form  ;  syphilis  ;  chronic 
malaria  ;  chronic  alcoholism  ;  chronic  mercurialism  ;  lead  poisoning  ; 
protracted  suppuration  ;  some  undetermined  nervous  condition. 

It  is  a  disease  of  the  young,  rarely  occurring  after  forty. 

Pathological  Anatomy.  A  large  white,  or  yellowish-white, 
smooth  kidney,  often  twice  the  normal  size.  The  capsule  is  nowhere 
adherent  to  the  organ.  Upon  section,  considerable  tumefaction  of 
the  cortical  substance  and  the  rarity  of  vascular  striae  are  recognized. 
The  medullary  substance  shows  no  appreciable  alteration,  its  color 
being  normal.  The  convoluted  tubes  are  irregularly  dilated  and 
thickened,  and  filled  with  broken-down,  granulated  epithelium  and 
fibrinous  casts.  In  pronounced  cases  there  is  fatty  degeneration  of 
the  tubular  epithelium. 

"The  intertubular  matrix  is  greatly  thickened — a  change  due  to 
hyperplasia  of  the  connective-tissue  elements,  to  the  migration  of  the 
white  corpuscles  and  their  subsequent  multiplication  and  fatty  trans- 
formation, and  to  a  quantity  of  fluid  exudation,  the  product  of  the 
increased  pressure  in  the  veins." 

Symptoms.  The  onset  is  gradual  and  insidious,  and  the  affec- 
tion is  seldom  recognized  until  the  appearance  of  dropsy,  which, 
beginning  under  the  eyes  and  in  the  face,  extends  all  over  the  body, 
causing  dyspnosa  from  ascites  or  hydrothorax,  although  in  many 
cases  the  dropsy  is  a  late  symptom,  the  patient  becoming /-a:/^,  debili- 
tated s^nd  suffering  from  cardiac  palpitatioji,  increasing  dyspficea,  and 
vo7niting,  all  gradually  developing  without  apparent  cause ;  also 
headache,  vertigo  and  defective  visio?t.  The  tirine  is  scanty,  high- 
colored,  albuminous ,  and  under  the  microscope  showing  hyaline  and 
granular  tube  casts,  granular  epithelium,  and  if  fatty  degeneration 
occur,  fatty  tube  casts  and  oil  globules.  The  increase  above  the 
normal  amount  of  the  urine  as  the  disease  progresses  must  not  be 
forgotten,  when  the  specific  gravity  is  low,  1.010-1.015,  and  the  quan- 
tity of  albumin  is  increased.  Irritable  bladder  is  a  very  constant 
symptom. 


128  PRACTICE   OF   MEDICINE. 

AncEJuia  is  pronounced,  from  the  large  waste  of  albumin.  Gastro- 
intestinal disorders  and  vague  neuralgic  pains  are  common  occur- 
rences. Cardiac  hypertrophy  is  of  common  occurrence.  Bronchial 
catarrh,  with  slight  cedevia  of  the  larynx,  causing  husky  voice,  are 
frequent  complications.  Amaurosis,  the  result  of  neuro-retifiitis, 
occurs  in  a  greater  or  less  degree  in  all  pronounced  cases.  Urcemic 
symptoms  occur,  and  especially  urcemic  asthma  (renal  asthma). 

Complications.  Pneumonia,  pleuritis,  pericarditis,  peritonitis, 
menmgitis,  and  cardiac  hypertrophy. 

Prognosis.  Not  unfavorable,  unless  urine  persistently  contains 
a  large  number  oi  fatty  tube  casts  and  oil  globules.  Relapses  are 
frequent,  but  many  complete  (?)  recoveries  are  recorded,  I  have  seen 
four  apparent  recoveries,  one  after  twelve  months'  duration,  another 
after  two  years'  duration,  and  still  another  after  five  years'  duration 
no  return  showing  itself  after  two  years. 

Treatment.  It  is  to  be  borne  in  mind  that  the  course  of  a  case 
of  chronic  Bright's  disease  is  not  continuously  downward ;  periods  of 
remission  often  follow  the  most  aggravated  symptoms,  the  patient 
and  his  friends  being  buoyed  into  the  hope  of  an  early  and  complete 
recovery,  when,  as  suddenly,  an  attack  of  acute  uraemia  terminates 
life. 

Rest  and  diet  are  important  elements  in  the  treatment. 

A  patient  with  chronic  Bright's  disease  should,  as  far  as  possible, 
be  relieved  from  all  cares  of  business  and  spend  a  goodly  portion  of 
time  in  bed. 

The  diet  should  be  entirely,  or  as  nearly  so  as  possible,  a  milk  diet, 
the  daily  amount  used  being  from  two  to  four  quarts.  The  moderate 
use  of  a  light  wine  is  at  times  of  advantage  if  taken  with  the  food, 
although  a  fair  number  of  cases  do  better  without  stimulants. 

The  use  of  diaphoretics  and  hydragogue  cathartics  are  only  indi- 
cated when  the  dropsy  is  marked,  the  skin  harsh  and  dry,  the  urinary 
secretion  scanty  and  uraemic  symptoms  are  threatening,  for  which 
administer  the  following  : — 

R  .     Ilydrargyri  chlor.  mite, 

Pulv.  scillse, 

Pulv.  digital., aa gr.  j.  M. 

Et  ft.  pil. 
SiG. — Three  times  daily  for  a  few  days. 

Diuresis  should  be  promoted,  if  the  secretion  is  small,  by  digitalis, 


DISEASES    OF   THE   KIDNEYS.  129 

casein  or  arbiitin  internally,  and  dry  cups  and  poultices  over  the 
loins. 

Iron  is  preeminently  the  drug  for  this  variety  of  Bright's  disease, 
the  tinctura  ferri  chloridum  the  best  form  for  administration. 

The  ajicemia  is  to  be  treated  by  oleum  7norrkii6s,  arseniciim  and 
ferrum,  an  excellent  formula  for  the  latter  being — 

R .     Strychninos  sulph., S^'  /^ 

Tinct.  ferri  chloridi,       .    .    .  f^ss 

Acidi  acetici  purae, fziss 

Curacose  alba f ^j 

Liq.  ammonii  acetat., ad  .    .    .    .  f^^vj.  M. 

SiG. — Tablespoonful  every  five   hours,  followed   by   a  glass   of  cold 
water. 

Another  good  formula  is — 

R .     Hydrargyri  chlor.  corrosiv., gr.  j 

Aurii  et  sodii  chloridi, •    •  gr.  j 

Ferri  per  hydrogen, gr.  xxiv.         M. 

Ft.  pil.  xxiv. 

SiG. — A  pill  after  meals. 

To  check  the  waste  of  albumin,  a  difficult  matter,  the  following 
remedies  have  been  used  with  more  or  less  success:  ergota,  quinina, 
acidum  gallicum,  acidum  bejtzoicitm,  tinctura  cantharidis,  potassii, 
iodidum,  and,  lastly,  the  Russian  remedy,  blatta  orientalis  (cock- 
roach). 

For  dropsy,  purgatives,  such  as  pulvis  jalapa  co7npositus,  hydra- 
gogue  cathartics  and  alkaline  mineral  waters;  act  on  skin  with  vapor 
baths,  or  pilocarpus  inuriat.,  gr.  yi,  repeated  if  not  much  cardiac 
depression,  or  combining  pulvis  ipecacua7thcE  et  opii,  gr,  iij,  with 
potassii  nitras,  gr.  iij-v,  every  tw^o  or  three  hours.  If  there  be  great 
distention  of  the  serous  cavities,  interfering  with  the  respiration,  the 
aspirator  ^o\A^  be  used.  Puncture  of  the  skin  may  be  necessary  at 
times,  and  is  well  accomplished  with  an  ordinary  cambric  needle. 

Cases  due  to  syphilis,  if  the  loss  of  renal  structure  is  slight,  are 
cured  by  a  course  of  hydrargyri  corrosivwn  chloridum  and  potassii 
iodidum  with  oleicm  morrhucE. 
II 


130  PRACTICE   OF   MEDICINE. 

INTERSTITIAL  NEPHRITIS. 

Synonyms.  Chronic  Bright's  disease  ;  sclerosis  of  the  kidneys  ; 
contracted  kidneys  ;  small  red  kidney  ;  gouty  kidney. 

Definition.  An  inflammation  of  the  intervening  connective 
tissue  of  the  kidney,  chronic  in  its  progress,  resulting  in  an  induration 
or  hardening,  with  contraction  of  the  organ  ;  characterized  by  frequent 
passing  of  large  amounts  of  pale,  albuminous  urine,  of  low  specific 
gravity,  disorders  of  the  gastro-intestinal  and  nervous  systems,  and 
a  strong  tendency  to  cardiac  hypertrophy  and  changes  in  the 
vessels. 

Causes.  A  disease  of  middle  life,  from  forty  to  sixty  years. 
Gout  a  very  common  cause ;  lead  cachexia ;  syphilis  ;  alcoholism  ; 
long-continued  worry,  anxiety  or  grief ;  alterations  in  the  renal  gan- 
glionic centres  (DaCosta  and  Longstreth). 

Pathological  Anatomy.  The  kidneys  are  reduced  in  size. 
The  capsule  is  thickened,  opaque  and  adherent.  The  surface  of 
the  kidney  is  granular,  with  cysts  of  various  sizes,  of  transparent 
color,  irregularly  over  the  surface.  On  section  the  tissue  of  the 
kidney  is  tough  and  resistant.  The  cortical  portion  is  thin,  from 
atrophy,  being  only  a  line  or  two  in  thickness.  The  C07i7iective  tissue 
is  greatly  thickened,  compressing  the  tubules  into  mere  threads,  the 
glomeruli  being  grouped  together  in  bunches,  owing  to  the  wasting  of 
the  intermediate  tubes.  The  color  varies,  from  a  darkish-brown  to  a 
yellowish-gray,  according  to  the  amount  of  blood  in  the  organ. 

The  left  side  of  the  heart  is  hypertrophied,  and  there  is  also  hyper- 
trophy of  the  muscular  fibre  of  the  arterioles  throughout  the  body ;  if 
the  case  is  protracted  the  hypertrophied  tissues  undergo  fatty  degene- 
ration. 

In  many  cases  there  occur  fatty  degeneration  of  the  retinal  tissues, 
or  sclerosis  of  the  nerve-fibre  layer,  changes  which  are  termed 
retinitis  albuminuria. 

The  ''  ganglionic  centres''  undergo  fatty  degeneration  and  atrophy 
(DaCosta  and  Longstreth). 

Apoplexy  is  a  frequent  termination  of  interstitial  nephritis,  the 
rupture  of  a  cerebral  vessel  suggesting  it  to  be  a  disease  of  degene- 
ration. 

Symptoms.  Onset  insidious,  and  often  marked  alterations  in 
the  kidneys,  heart  and  vessels  have  occurred  before  the  disease  is 
recognized.     There   are   no    characteristic    early   symptoms   in   the 


DISEASES   OF   THE   KIDNEYS.  131 

majority  of  cases,  the  disease  being  apparently  latent,  until  some  spe- 
cial outbreak  cause  a  more  thorough  examination  of  patient,  when  he 
is  found  to  have  an  interstitial  nephritis. 

Any  of  the  following  symptoms  may  first  attract  attention,  to  wit : 
frequent  micturition,  increased  amount  of  urine  of  a  pale  color, 
containing  a  small  amount  of  albumin,  which  may  be  absent  for 
days,  occasional  epithelial  cells  and  hyaline  casts.  No  dropsy,  but  a 
little  puffiness  and  (sdejna  of  the  coiijunctiva — the  Bright' s  eye.  Dis- 
orders of  vision.  Forcible  cardiac  action  with  high  arterial  tension. 
And  any  of  the  following  symptoms,  the  result  of  urcE?nia  :  Persistent 
dyspepsia,  occasional  vomiting,  regardless  of  food  ;  headache,  vertigo 
and  stupor  ox  drowsiness  ;  violent  itchi?tg  oi  the  skin  ;  trejnors,  con- 
vulsiojts,  epileptic  seizures,  or  apoplectic  attacks. 

The  body  weight  declines,  the  skin  is  dry  and  scurfy,  the  strength 
fails,  and  shortness  of  breath  on  exertion  is  present. 

The  termination  is  usually  by  convulsions,  coma  and  death. 

Complications.  Bronchitis;  pneumonia;  pleuritis;  pericarditis; 
cardiac  hypertrophy. 

Diagnosis.  Differs  ixova  parenchymatous  nephritis  in  the  follow- 
ing :  large  quantity  of  urine,  clear,  of  low  specific  gravity,  small 
amount  of  albumin,  with  few  hyaline  casts  ;  the  hypertrophied  heart 
and  tense  arteries  and  marked  disorders  of  vision. 

Prognosis.  Pursues  a  very  chronic  course  ;  cases  recorded  under 
observation  eleven  years  ;  but  the  termination  is  always  fatal. 

Treatment.  Regulated  diet.  Diaphoretics.  Diuretics.  Avoid 
alcoholic  stimulants.  As  nearly  absolute  rest  as  patient's  general 
health  will  permit. 

To  prevent  the  growth  of  the  connective  tissue,  the  following  reme- 
dies are  recommended,  to  wit:  potassii  iodidum,  hydrargyri  corrosi- 
vum  chloridum,  gr.  2V.  cLurii  et  sodii  chloridum,  gr.  ^^i  f^f^i  iodidum 
and  arsenicum. 

For  urczmia,  if  patient  is  conscious,  purgatives,  diaphoretics  and 
diuretics.  If  unconscious,  morphina  hypodermically  or  chloroforfn 
inhalations. 

AMYLOID  KIDNEY. 

Synonyms.  Chronic  Bright's  disease  ;  waxy  kidney  ;  lardaceous 
kidney. 

DeJSnition,     A  peculiar  infiltration    into,    or  a   degeneration  of, 


132  PRACTICE   OF   MEDICINE. 

the  Structure  of  the  kidney,  from  the  deposit  of  an  albuminoid  mate- 
rial, having  a  superficial  resemblance  to  starch  granules.  Similar 
changes  occur  in  the  liver,  spleen,  intestines,  and  other  organs. 

Causes.  The  chief  cause  is  prolonged  suppuration,  especially  of 
the  bones  ;  coxalgia  ;  syphilis ;  cancer. 

Pathological  Anatomy.  The  kidney  is  uniformly  enlarged. 
It  presents  a  pale,  glistening,  translucent  appearance,  and  has  a 
doughy  consistency.  On  section,  the  surface  is  homogeneous, 
anaemic  and  whitish.  The  deposit  occurs  along  the  renal  vessels  and 
in  the  vascular  tufts  of  the  glomeruli,  progressing  until  all  parts  of 
the  organ  are  infiltrated.  When  the  organ  is  thus  infiltrated,  the 
proper  structure  undergoes  an  atrophic  degeneration,  the  result  of 
pressure. 

The  reaction  with  iodine  and  sulphuric  acid  affords  a  certain  test 
of  the  atnyloid  deposit.  Brush  over  a  section  of  the  affected  kidney 
a  solution  of  iodine  with  iodide  of  potassium  in  water,  when  a 
mahogany  color  will  be  produced,  and  if  diluted  sulphuric  acid  is 
now  added,  a  violet  or  bluish  tint  results.  A  very  pretty  reaction  is 
to  take  a  one  per  cent,  solution  of  anilin  violet,  which  strikes  a  red  or 
pink  color  with  the  amyloid  material,  while  the  unaltered  tissues  are 
stained  blue,  making  a  beautiful  contrast. 

Similar  changes  occur  in  other  organs  of  the  body.  "With  the 
amyloid  change  may  be  associated  either  parenchymatous  or  inter- 
stitial nephritis. 

Symptoms.  Associated  with  wasting  are  cedevia  of  the  lower 
extremities  and  ascites,  with  an  increased  flow  of  urine,  pale,  watery, 
and  of  low  specific  gravity,  containing  albiunin  and  hyaline  casts 
which  are  transparent.  If  the  amyloid  change  be  associated  with 
other  forms  of  renal  change,  the  urine  will  show  the  characteristics  of 
such  condition.  A  profuse,  watery  and  persistent  diarrhosa  adds  to 
the  suffering,  caused  by  amyloid  changes  in  the  intestinal  canal. 

Diagnosis.  Differs  from  parenchymatous  nephritis  in  its  clinical 
history,  and  the  fact  of  its  always  being  associated  with  a  suppurating 
disease. 

From  interstitial  nephritis,  in  its  history,  character  of  the  urine, 
absence  of  uraemia,  cardiac  hypertrophy,  changes  in  the  vessels,  and 
the  fact  of  its  association  with  suppurating  diseases  and  similar 
changes  in  other  organs. 

Prognosis.     Controlled  by  the  suppurating  disease  with  which  it 


DISEASES   OF  THE   KIDNEYS.  133 

is  associated  ;  the  termination,  when  the  amyloid  change  is  fully- 
developed,  is  unfavorable,  death  occurring  within  a  few  months,  or 
under  favorable  conditions,  not  for  one  or  more  years. 

Treatment.  Sustaining  and  symptomatic  in  character.  Gener- 
ous diet,  and  the  persistent  use  of  ferri  iodidum,  alternating  with 
ammonii  niurias  and  oleum  morrhucE. 

If  caused  by  syphilis,  a  thorough  course  oi  potassii  iodidum,  ferri 
iodidum  and  hydrargyri  corrosiviim  chloridujn,  with  oleum  morrkuce. 

PYELITIS. 

Synonyms.     Suppurative  nephritis  ;   pyelo-nephritis. 

Definition.  An  acute  catarrhal  inflammation  of  the  pelvis  of  the 
kidney  ;  the  term  pyelo-nephritis  is  used  when  suppurative  inflamma- 
tion is  superadded  to  the  catarrhal  inflammation.  The  disease  is 
characterized  by  lumbar  pains,  irritability  of  the  bladder,  the  urine 
neutral,  or  alkaline  in  reaction,  and  milky  in  appearance  ;  if  pyelo- 
nephritis occur,  symptoms  of  hectic  fever  and  exhaustion  are  added, 
the  urine  containing  pus. 

Causes.  Cold,  or  exposure ;  cystitis  ;  obstruction  of  the  ureters 
by  renal  calculi ;  pressure  from  a  tumor ;  abuse  of  certain  drugs  ; 
rheumatism  ;  sequels  of  infectious  diseases. 

Pathological  Anatomy.  The  inflammation  is  catarrhal ;  it  is 
characterized  by  injection  of  the  mucous  membrane  of  the  pelvis  of 
the  kidney,  with  slight  extravasations  of  blood ;  relaxation  and  soft- 
ening, shedding  of  the  epithelium,  and  the  subsequent  discharge  of 
mucus  and  pus.  If  the  morbid  condition  has  existed  for  some  time, 
the  kidneys,  one  or  both,  are  in  process  of  suppuration,  they  are 
enlarged,  deeply  congested,  except  where  suppuration  is  proceeding, 
when  they  are  of  a  yellowish-white  color — pyelo-nephritis.  Pus  is 
constantly  forming,  and,  if  there  be  no  obstruction,  flows  away  with 
the  urine ;  should  there  be  an  impediment  to  its  escape,  pus  accumu- 
lates in  the  pelvis  of  the  kidney,  causing  its  distention,  giving  rise  to 
the  condition  known  as  pyelo-Jiephritis.  The  pressure  caused  by  the 
obstruction  finally  leads  to  destruction  of  the  entire  organ,  a  mere  sac 
or  renal  cyst  remaining. 

Symptoms.  If  caused  by  cystitis,  symptoms  of  this  condition 
occur  first ;  if  from  renal  calculi,  its  characteristic  symptoms  precede 
those  of  pyelitis. 


134  PRACTICE   OF   MEDICINE. 

Begins  by  chilliness,  feverishness,  liunbar  pains  following  the 
course  of  the  ureters,  frequent  micturition,  the  urine  milky  in  appear- 
ance when  voided,  acid  or  neiitral  in  reaction,  and  depositing  a 
copious  sediment,  whitish  or  yellowish-white  in  color,  containing 
only  a  small  amount  of  albumin,  no  more  than  is  due  to  ih^pus. 

Cases  of  pyelitis  due  to  renal  calculi  frequently  show  hemorrhages  ; 
the  bloody  urine  after  some  extra  exertion. 

If  pyelo-nephritis  follow,  symptoms  of  pyaemia  supervene,  to  wit : 
fever,  typhoid  in  character,  low,  muttering  delirium,  subsultus  tendi- 
man,  stupor,  decline  in  strength  and  loss  of  flesh,  with  perhaps  a 
ticmor  in  the  lumbar  region. 

If  both  kidneys  are  affected  urcEmic  symptoms  are  frequent. 

Diagnosis.  From  cystitis,  by  history,  lumbar  pains  and  acidity 
of  purulent  urine,  the  urine  in  cystitis  being  always  alkaline.  A 
microscopical  examination  of  the  urine  will  aid  the  diagnosis  very 
much. 

Peri-nephritis,  a  disease  of  loose  tissue,  around  about  the  kidneys, 
terminating  in  abscess,  causing  lumbar  pain,  increased  by  motion  or 
pressure,  hectic  fever,  sense  of  fluctuation  over  kidneys,  the  urine 
remainittg  7iormal. 

Prog'nosis.  Simple  cases,  where  there  is  no  obstruction  to  flow  of 
pus,  recover  in  a  week  or  ten  days.  If  obstruction  of  the  ureter,  the 
prognosis  is  grave.     Suppurative  cases  unfavorable. 

Treatment.  Rest  in  bed.  Milk  diet.  Free  use  of  water  to 
dilute  the  urine,  and  free  diaphoresis.  Quinifia  to  keep  down  tem- 
perature, prevent  formation  of  pus,  and  maintain  the  powers  of  life. 

To  change  the  character  of  the  secretion.  Prof.  DaCosta  strongly 
recommends  pix  liquida  ;  other  remedies  are  oleu?n  santali,  copaiba, 
eucalyptol,  terebinthina,  and  cubeba.  I  have  seen  excellent  results 
from  a  prolonged  course  of  the  Buffalo  Lithia  Springs  water  or  the 
Rockbridge  Alum  Springs  water  of  Virginia. 

For  renal  hemorrhage,  alume^t,  gr.  xx,  repeated  p.  r.  n.,  is  suc- 
cessful. 

If  abscess  results,  aspiration,  quinina  and  stimulants.  Extirpation 
of  the  diseased  kidney  has  been  followed  with  fair  health. 


DISEASES    OF   THE    KIDNEYS.  135 

ACUTE  UREMIA. 

S3monynis.  Ursemic  poisoning  ;  urasmic  intoxication  ;  uraemic 
coma;  uraemic  convulsions. 

Definition.  A  group  of  nervous  phenomena,  which  occasionally 
develop  during  the  course  of  acute  or  chronic  Bright's  disease,  and 
other  maladies,  the  result  of  the  retention  or  accumulation  in  the 
blood  of  an  excrementitious  material,  supposed  to  be  urea  ;  the  flow 
of  urine  being  either  normal,  lessened  or  increased. 

Causes.  Suppression  of  urine,  from  acute  or  chronic  Bright's 
disease  ;  cystic,  tubercular  or  cancerous  kidney ;  the  puerperal  state  ; 
operations  on  the  uterus,  bladder,  urethra  or  rectum. 

Symptoms.  Ursemic  intoxication  is  the  result  of  the  failure  of 
the  kidneys  to  perform  their  normal  function  of  eliminating  some  one 
or  all  of  the  poisonous  elements  of  the  urine. 

The  toxaemia  may  develop  suddenly,  by  a  convulsive  seizure  fol- 
lowed by  coma,  or  slowly  and  gradually.  Usually  the  attack  is  pre- 
ceded by  a  decrease  in  the  urinary  secretion  ;  although  it  must  be 
borne  in  mind  that  in  rare  instances,  during,  or  immediately  prior  to, 
the  appearance  of  the  uraemic  phenomena,  the  normal  urinary  flow 
has  been  largely  exceeded. 

The  onset  is  usually  with  headache,  dimness  of  vision,  dilated,  slug- 
gish pupils,  drowsiness,  vertigo,  deafness,  dusky  countenance,  nausea, 
vomiting,  and  either  a  chill  followed  by  fever,  or  a  cool  skin  from 
the  onset ;  the  mind  is  dull,  deepening  into  stupor,  to  be  followed  by 
coma,  or  convulsions  precede  the  coma,  which  terminates  in  death, 
unless  the  poison  causing  the  attack  is  rapidly  eliminated.  If  the 
amount  of  accumulated  urea  is  small  the  phenomena  may  not 
approach  the  pronounced  coma  described,  the  patient  being  able  to 
be  aroused.  When  convulsions  occur  they  rapidly  succeed  one 
another,  consciousness  seldom  being  complete  between  the  fits. 

Diagnosis.  Cerebral  apoplexy  may  be  mistaken  for  uraemic 
coma,  or  the  reverse.  The  chief  points  of  distinction  are,  in  the  latter 
the  attack  is  usually  in  patients  suffering  from  dropsy,  and  that  the 
coma  is  not  sudden  in  its  appearance,  but  is  generally  preceded  by 
other  nervous  phenomena,  such  as  headache,  vertigo,  dimness  of 
vision,  obstinate  vomiting,  and  convulsions.  Again,  the  urcnmic 
stertor  IS  a  sharp,  hissing  sound,  while  that  of  apoplexy  is  "snoring." 
Apoplexy  is  followed  by  paralysis,  uraemic  coma  is  not. 

An  epileptic  seizure   is  preceded  by  the  sharp  cry  and  extreme 


13^  PRACTICE   OF   MEDICINE. 

pallor  of  the  face,  the  countenance  being   dusky   in  urasmic  con- 
vulsions. 

Prognosis.  An  attack  of  acute  uraemia  is  always  a  very  grave 
condition.  The  prognosis  depends  upon  the  amount  of  retained 
poison,  the  length  of  time  it  has  been  retained,  and  the  condition  of 
the  organs  of  elimination. 

Treatment.  The  indications  in  acute  uraemia  are :  first,  to 
arrest  the  nervous  phenomena;  secondly,  to  promote  elimination. 
Prof.  Loomis  has  succeeded  in  meeting  both  of  these  indications  by 
hypodermic  injections  oimorphina,  gr.  Ye-yi-yi,  repeated,  if  required, 
every  two  hours.  He  says,  "the  most  uniform  effect  of  morphine  so 
administered  is,  first,  to  arrest  muscular  spasms;  second,  to  establish 
profuse  diaphoresis ;  third,  to  facilitate  the  action  of  cathartics  and 
diuretics,  especially  the  diuretic  action  of  digitalis." 

Following  the  injection  of  morphina,  diaphoresis  should  be  pro- 
moted by  means  of  the  vapor-bath,  or  the  hot  wet-pack,  or  the  hypo- 
dermic use  oi  pHocarpijicE  hydrochloras,  gr.  yV~/^~X»  provided  no 
counter-mdication  to  its  use  exists,  or  frequent  doses  of  caffeina. 

The  co7ivuhive  phenomena  are  rapidly  controlled  by  inhalations  of 
chlorofonnwn,  or  the  internal  or  rectal  administration  of  chloral. 

Diuresis  should  be  promoted  by  infusmn  digitalis,  and  dry  or  wet 
cupping,  and  poultices  over  the  loins. 

Catharsis  is  best  produced  by  elaterium,  gr.  xV"3^- 

For  warding  off  attacks  of  uraemia,  good  results  follow  the  use 
of  acidum  be7izoicmn,  acidiim  nitricum  dilutum,  or  acidum  hydro- 
chloricwn  dilutum,  in  small,  frequently  repeated  doses. 

RENAL  CALCULI. 

Synonyms.     Nephro-lithiasis  ;  gravel ;  renal  colic. 

Definition.  Renal  calculi  are  concretions  formed  by  the  precipi- 
tation of  certain  substances  from  the  urine,  around  some  body  or 
substance  acting  as  a  nucleus. 

Their  presence  may  not  be  recognized  until  one  or  more  attempts  to 
pass  along  the  ureters,  when  an  attack  of  renal  colic  results  ;  or,  by 
irritation,  pyelitis  is  produced  ;  or  more  rarely,  they  are  voided  by  the 
urine  without  exciting  any  symptoms. 

V>^  gravel  \s  meant  very  small  concretions,  which  are  often  passed 
in  the  urine  in  larg-e  numbers. 


DISEASES   OF  THE   KIDNEYS.  137 

Causes.  Occur  at  all  ages ;  frequent  before  the  fifth  year,  and 
from  five  to  fifteen.  Males  are  more  liable  than  females.  A  special 
liability  seems  to  exist  in  some  families,  but  the  precise  etiology  of 
calculi  is  not  yet  determined. 

Varieties,  i.  Uric  acid,  as  calculi  and  gravel,  and  especially 
associated  with  the  gouty  diathesis. 

2.  Urates,  chiefly  urate  of  ammonia ;  nearly  always  in  childhood. 

3.  Oxalate  of  Ihne  or  mulberry  calculus;  characterized  by  hardness, 
roughness,  and  very  dark  color. 

4.  Phosphatic  calculi  form  as  frequently  in  the  bladder  as  in  the 
kidney,  and  present  a  chalky  or  earthy  appearance. 

5.  Alternating  calciili,  consisting  of  alternate  layers  of  two  or  more 
primary  deposits. 

Anatomical  Characters.  In  structure,  a  urinary  calculus 
u  sually  consists  of  a  central  nucleus,  surrounded  by  the  body,  and 
o  utside  of  all  there  may  be  a  phosphatic  crust.  The  nucleus  may  or 
may  not  be  of  the  same  material  as  the  rest  of  the  stone,  sometimes 
being  a  foreign  body,  mucus,  or  blood. 

A  section  generally  shows  a  stratified  arrangement,  or  it  may  be 
partly  or  completely  radiated. 

Symptoms.  The  clinical  signs  of  renal  calculi  are  those  con- 
sequent on  the  results  of  their  presence,  to  wit :  renal  hetnorrhage, 
re7ial  congestion,  i7iflammation,  terminating  in  abscess,  pyelitis,  or 
pyelo-nephritis,  cystitis,  or  renal  colic. 

The  symptoms  of  renal  colic  begin  abruptly,  by  severe,  agonizing 
pain  in  the  lumbar  region,  following  the  ureters  into  the  corres- 
ponding groin  and  thigh.  Paiji  and  retraction  of  corresponding 
testicle,  also  of  glans  penis.  Face  pale  and  features  pinched,  the 
surface  cold  and  damp.  Irritability  of  the  bladder,  the  urine  passed 
in  drops  containing  some  blood.  So  severe  is  the  pain  at  times 
that  the  patient  may  faint  or  pass  into  unconsciousness,  or  have  a 
general  convulsion.  If  both  ureters  are  obstructed,  tircemic  symptoms 
will  arise. 

The  paroxysm  usually  terminates  suddenly  after  some  minutes  or 
hours,  the  stone  escaping  into  the  bladder. 

Prognosis.  Renal  calculus  is  attended  with  many  dangers.  It 
may  produce  extensive  disorganization  of  the  kidneys,  or  its  passage 
along  the  ureter  may  prove  fatal.  If  the  stone  be  very  large,  or  if 
more  than  one,  the  prognosis  is  graver.     Calculus  is  a  disease  very 


138  PRACTICE   OF   MEDICINE. 

apt  to  recur.  Renal  sand  {gravel)  and  small  concretions  may,  after 
more  or  less  delay,  be  voided  with  the  urine. 

Treatment.  An  attack  of  re?ial  colic  is  best  relieved  by  a 
hypodermic  injection  of  niorphina  and  atropina,  and  a  warm  bath  or 
a  suppository  oi  ext.  opii,  gr.  j  ;  ext.  belladofincB  alco.,  gr.  ss,  repeated 
if  needed. 

For  attacks  of  gravel,  liquor  potassii  citratis,  f^ss,  every  three 
hours,  and,  if  much  vesical  irritability,  adding  tinct.  opii  cainph. 
f3ss-j. 

Y ax  renal  hemorrhage,  Prof.  Bartholow  reports  success  with 

R  .     Extracti  ergotae  fluidi, 

Tincturae  krameriae, aa ^  ij.  M. 

SiG. —  3J  every  two  or  more  hours. 

I  have  always  successfully  controlled  renal  hemorrhages  with 
twenty-grain  doses  of  ahiine?t,  repeated  p.  r.  n. 

For  uric  acid  calculi,  as  a  solvent,  Buffalo  Lithia  Springs  water  or 
the  Rockbridge  Alum  Springs  watec  of  Virginia,  or  potassii  tartra- 
borates,  "  obtained  by  heating  together  four  quarts  of  cream  of  tartar, 
one  part  of  boracic  acid,  and  ten  parts  of  water.  A  scruple  may  be 
given  three  or  four  times  a  day,  in  water,  largely  diluted." 

For  phosphatic  calculi,  as  a  solvent,  ammonii  benzoas,  well  diluted 
and  long  continued. 

CYSTITIS. 

Synonym.     Catarrh  of  the  bladder. 

Definition.  An  inflammation  of  the  mucous  membrane  lining 
the  urinary  bladder,  acute  or  chronic  in  its  course,  and  of  either  a 
catarrhal,  croupous,  or  diphtheritic  character ;  characterized  by  rigors, 
moderate  fever,  hypogastric  pain,  frequent  but  scanty  micturition  and 
severe  vesical  tenesmus,  the  urine  containing  pus. 

Causes.  Acute  variety ;  long  retention  of  urine;  foreign  bodies 
in  the  bladder;  pyelitis;  urethritis;  blows  over  the  pubes  ;  myelitis, 
and  secondary  to  fevers  or  diphtheria.  Chronic  variety:  following 
the  acute  variety ;  retention  the  result  of  enlarged  prostate  or  an 
urethral  stricture ;  calculi;  gout;  chronic  Bright's  disease. 

Pathological  Anatomy.  In  acute  catarrhal  cystitis,  there  first 
ensues  hyperccmia  of  the  mucous  membrane  of  the  entire  or  a  por- 
tion of  the  bladder,  manifested  by  redness,  swelling  and  oedema; 


DISEASES   OF   THE    KIDNEYS.  139 

followed  by  an  increased  secretion  of  the  small  glands  at  the  base  of 
the  bladder,  and  an  increased  growth  and  consequent  desquamation 
of  the  vesical  epithelium,  together  with  a  copious  generation  of  young 
cells  ;  if  the  hypersemia  be  decided,  rupture  of  the  capillaries  and 
extravasation  of  blood  occur. 

If  the  inflammation  be  intense  suppuration  of  the  sub-mucous  con- 
nective tissue  may  result,  and  ulceration  of  the  mucous  membrane 
permit  the  sub-mucous  abscesses  to  empty  into  the  bladder. 

If  the  inflammation  be  of  a  croupous  or  diphtheritic  character,  the 
morbid  anatomy  does  not  differ  from  the  same  variety  of  inflamma- 
tions in  other  mucous  membranes. 

In  chro7iic  cystitis  "the  mucous  membrane  is  thick,  blue-gray  in 
color,  and  very  tough.  Muco-pus  and  viscid  mucus  are  formed  in 
large  quantities  upon  its  surface.  The  muscular  wall  of  the  bladder 
may  sometimes  be  half  an  inch  thick,  and  the  fasciculi  give  a  ribbed 
appearance  to  the  internal  surface,  called  the  '  columnar  bladder.' 
The  hypertrophy  of  chronic  cystitis  may  be  eccentric  or  concentric. 
In  some  cases  diverticuli  are  formed,  in  whose  walls  are  dilated  and 
tortuous  veins.  In  nearly  all  cases  bacteria  are  found  in  abundance." 
(Loomis.) 

Symptoms.  Acute  cystitis ;  the  onset  is  usually  abrupt,  by  rigors, 
slight  fever,  loss  of  appetite,  sleeplessness,  a  feeling  of  depression  ; 
frequent  micturition,  but  the  urine  is  only  voided  drop  by  drop,  its 
passage  followed  by  distressing  vesical  tenesmus,  the  result  of  spasm 
of  the  bladder ;  pain  over  the  pubis  and  in  the  iliac  regions,  of  a  dull 
character,  at  times  becoming  sharp  and  agonizing  ;  burning  along  the 
urethra  adds  to  the  distress  of  the  patient. 

The  uritie  is  cloudy,  of  an  alkaline  reaction,  and  at  times  is  fetid, 
the  microscope  showing  epithelium,  and  red  blood  corpuscles. 

Chronic  cystitis  ;  the  onset  is  gradual  and  insidious,  and  is  excited 
by  some  obstacle  to  the  evacuation  of  the  urine,  such  as  stricture, 
the  presence  of  a  stone  in  the  bladder,  or  enlargement  of  the  prostate 
gland.  There  are  present  dull  pain,  frequent  but  scanty  micturi- 
tion, the  tirine  is  alkaline,  containing  large  amounts  of  muco-pus  or 
pus ;  on  standing,  it  deposits  a  thick,  glairy,  viscid  sediment,  in 
which,  under  the  microscope,  triple  phosphates  and  large  pus  cor- 
puscles, extremely  regular  both  in  contents  and  in  shape,  may  be 
detected. 

Although  the  quantity  of  urine  voided  by  the  patient  is  small,  yet 


140  PRACTICE   OF   MEDICINE. 

if  immediately  after  micturition  the  catheter  is  used,  several  ounces 
oi fetid,  cloudy,  alkaline  tirine  may  be  removed. 

Patients  with  chronic  cystitis  usually  present  decided  constitutional 
debility. 

Severe  local  pain,  emaciation  and  occasional  bloody  urine,  indi- 
cate ulceration  of  the  vesical  mucous  membrane. 

Diagnosis.  Pyelitis  has  lumbar  pains  following  the  course  of  the 
ureters,  frequent  micturition  without  the  severe  vesical  tenesmus  ;  the 
urine,  although  cloudy,  has  an  acid  or  neutral  reaction. 

Prognosis.  The  actite  variety  is,  as  a  rule,  good,  being  controlled 
by  the  cause. 

The  chronic  variety  continues  for  years,  and  after  hypertrophy  of 
the  bladder  is  incurable. 

Treatment.  Rest  is  paramount.  The  diet  must  be  restricted, 
all  highly-seasoned  articles  being  particularly  interdicted  ;  milk  is  the 
most  suitable  diet. 

Warm  applications  over  the  pubic  region  are  of  benefit;  and  leech- 
ing and  cupping  over  the  bladder  are  of  service. 

The  urine  should  be  well  diluted  by  large  draughts  of  pure  water 
and  particularly  the  alkaline  mineral  waters,  to  wit :  Farmville  Lithia, 
Buffalo  Lithia  or  the  Rockbridge  Alum,  or  Vichy  waters.  The  follow- 
ing formulae  are  of  decided  benefit : — 

R.     Acidi  benzoici, 

Sodii  borat., aa ^  i j 

Infusi  buchu,  vel., 

Infusi  uvse  ursse .    .  f  ^  vj.  M. 

SiG. — Tablespoonfu]  every  2  hours,  well  diluted. 
Or— 

R  .     Liquor,  potassje, f  .^  iij 

Mucil.  acacias, ad {"^  viij.  M. 

SiG. — Tablespoonfu]  every  4  hours,  well  diluted. 

For  the  pain  and  tenesmics  relief  is  afforded  by  a  suppository  of 
extractufn  opii  and  extractuvi  belladonncs,  repeated  as  needed. 

The  vesical  tenesmus  is  often  benefited  by  extractufn  cannabis 
indie CB  fiuiduin,  f.'^ss,  every  three  or  four  hours. 

Chro7iic  cystitis.  The  bladder  should  be  completely  emptied  with 
the  catheter  several  times  in  the  twenty-four  hours. 

The  use  of  eucalyptol,  gtt,  x-xv,  every  four  hours,  well  diluted,  or 
a  good  preparation  of  tar,  or  extractuin  griiidelia  fiuidtwi,  n\^xx-f  5j, 


DISEASES   OF   THE   KIDNEYS.  141 

three  or  four  times  daily,  and  washing  out  the  bladder  with  the  fol- 
lowing mixture,  has  been  of  decided  benefit  in  the  hands  of-  the 
author : — 

R.     Sodii  borat., , .^j 

Glycerin], f,^ij 

Aquae, f|ij.  M. 

SiG. — f^  ss-iss  added  to  warm  water  and  injected  into  the  bladder  once 
or  twice  daily. 

The  diet  should  be  nutritious,  but  without  spices  of  any  kind.     The 
free  use  of  the  alkaline  mineral  waters  is  of  advantage. 


MOVABLE  KIDNEY. 

Synonyms.     Floating  kidney  ;  wandering  kidney  ;  ectopia  renis. 

Definition.  A  condition  of  the  kidney,  either  congenital  or 
acquired,  in  which  the  tissues  around  about  the  organ  are  so  lax  and 
the  renal  vessels  so  elongated  as  to  permit  the  kidney  to  be  moved  in 
certain  directions,  causing  a  movable  tumor  in  the  abdomen. 

Causes.  The  kidney  is  normally  held  in  position  by  the  layer  of 
peritoneum  which  is  attached  to  the  anterior  surface  of  its  adipose 
capsule.  In  movable  kidney,  the  adipose  tissue  in  which  the  normal 
kidney  is  imbedded  partly  or  wholly  disappears. 

The  renal  vessels  are  in  many  cases  abnormally  long.  Relaxation 
of  the  abdominal  walls  from  pregnancy  or  other  causes.  The  use  of 
tight  corsets  or  girdles  about  the  waist ;  violence  ;  increased  weight 
of  the  organ  from  disease ;  the  pressure  of  tumors  growing  in  the 
neighborhood  of  the  kidney  ;  the  traction  of  hernias. 

The  condition  may  be  congenital  or  acquired,  more  frequently  the 
latter.     It  is  far  more  frequent  in  women  than  in  men. 

Symptoms.  Floating  kidney  may  and  often  does  exist  without 
any  noticeable  symptoms,  the  condition  being  unknown  until  acci- 
dentally discovered  by  the  physician  while  making  a  physical  exam- 
ination of  the  abdomen. 

As  a  rule,  however,  patients  experience  a  heavy,  dragging  pain  in 
the  abdomen,  aggravated  when  walking  or  standing.  There  are  also 
present  gastro-intestinal  symptoms,  more  or  less  constant,  with  melan- 
cholia aggravated  by  the  mental  anxiety  the  presence  of  a  twnor 
in  the  abdomen  causes  the  patient,  in  spite  of  the  assurances  of  the 
physician  that  it  is  not  a  cancer. 


142  PRACTICE   OF   MEDICINE. 

At  times,  from  some  unknown  or  unrecognized  cause,  the  movable 
kidney  swells  and  becomes  very  sensitive  to  the  touch,  and  migrates 
a  considerable  distance  from  its  normal  position.  Such  an  occurrence 
aggravates  all  the  former  symptoms  mentioned.  This  condition  has 
been  ascribed  to  a  twisting  of  the  ureter  and  consequent  retention  of 
the  urine  in  the  pelvis  of  the  kidney,  or  to  a  localized  peritonitis  or  to 
a  partial  strangulation  of  the  kidney  from  compression  or  twisting  of 
its  blood  vessels. 

Hysterical  symptoms  are  frequently  observed  in  women  suffering 
from  wandering  kidney. 

Diagnosis.  The  dislocation  of  the  kidney  is  to  be  recollected  in 
determining  the  nature  of  obscure  tumors  within  the  abdomen. 

The  late  Prof.  Austin  Flint  based  the  recognition  of  this  variety  of 
abdominal  tumor  on  the  following  diagnostic  points  :  "  It  is  situated 
in  the  hypochondriac  region.  It  has  the  size  and  shape  of  the  normal 
kidney,  and  this  may  be  determinable  by  palpation,  which  is  most 
advantageously  employed  by  placing  one  hand  over  the  lumbar  region 
and  the  other  in  front  on  the  abdominal  walls,  and  then  making  coun- 
ter-pressure from  one  hand  to  the  other.  It  is  generally  movable,  and 
in  some  cases  the  organ  can  be  restored  to  its  proper  situation." 

Other  tumors  are  to  be  excluded  by  the  absence  of  their  diagnostic 
characters. 

Prognosis.  It  is  a  rare  occurrence  to  have  a  fatal  termination 
from  movable  kidney  per  se. 

Treatment.  Symptomatic.  It  is  said  that  some  of  the  inconve- 
nience and  sometimes  suffering  attending  movable  kidney  may  be 
lessened  by  means  of  an  abdominal  bandage,  belt  or  supporter. 

If  attacks  of  pain  and  swelling  occur,  the  patient  should  be  placed 
in  bed,  hot  applications  over  the  abdomen,  the  use  of  opiates  and 
attempts  at  replacing  the  organ. 

Extirpation  of  a  movable  kidney  has  been  successfully  performed 
a  number  of  times. 

Nephrorrhaphy,  an  operation  for  fixation  of  the  kidney  by  means  of 
sutures,  has  been  devised. 


ACUTE  GENERAL   DISEASES.  143 


ACUTE  GENERAL  DISEASES. 


PAROTIDITIS. 

Synonym.    Mumps. 

Definition.  An  acute  specific  infectious  inflammation  of  one  or 
both  parotid  and  other  salivary  glands  and  the  surrounding  connect- 
ive tissue,  with  a  very  strong  tendency  to  migrate  into  the  mammae  or 
testes ;  characterized  by  pain,  swelling  and  disordered  function  of  the 
glands. 

Causes.  A  specific  poison.  Contagious.  Occurs  in  epidemics, 
although  isolated  cases  are  seen.  Males  more  liable  than  females. 
The  most  common  ages  between  five  years  and  puberty.  As  a  rule, 
it  occurs  but  once  in  the  same  individual. 

TYvQ.  period  of  incubation  is  from  one  to  three  weeks. 

Pathological  Anatomy.  There  is  inflammation  of  one  or  both 
parotid  glands,  and  in  severe  epidemics  the  cellular  tissue  pervading 
the  gland  is  involved. 

The  catarrhal  inflammation  begins  in  the  gland  ducts  and  rapidly 
extends  to  the  gland  proper.  There  is  congestion,  swelling  and  an 
infiltration  of  serous  fluid,  with  more  or  less  infiltration  of  the  adja- 
cent tissues.  The  swelling  may  suddenly  reach  an  enormous  size 
and  as  suddenly  decline,  the  gland  returning  to  its  normal  condition, 
or,  rarely,  an  abscess  results,  with  partial  or  complete  destruction  of 
the  gland.  Occasionally  the  submaxillary  gland  is  involved,  also  the 
mammae  and  testes. 

Metastatic  parotiditis  occurs  secondary  to  severe  blood  poisoning, 
as  in  pyaemia,  typhoid  or  typhus  fevers  or  diphtheria.  The  usual 
termination  of  secondary  parotiditis  is  by  suppuration  and  destruction 
of  gland  structure. 

Symptoms.  The  onset  is  rather  sudden,  by  malaise,  chill,  fever, 
ioi°-i03°  F.,  quick  pulse,  headache,  dry  skin,  scanty  tirine,  followed 
within  a  day  or  two  by  stiffness  at  the  angles  of  the  jaw,  swelling  of 
the  parotid  and  other  salivary  glands,  pai^t,  increased  by  moving  the 
jaws,  v/'\\h.  general  oedema  of  the  affected  side  of  the  face,  at  times  the 
skin  being  reddened.  Salivation  is  frequent,  and  occasionally  deaf- 
ness occurs. 

The   swelling  and  other  glandular  symptoms   subside   about  the 


144  PRACTICE   OF   MEDICINE. 

sixth  or  seventh  day,  to  be  followed  by  restoration  to  health,  or  what 
is  more  common,  the  involvement  of  the  opposite  gland. 

At  any  time  during  the  disease  metastasis  to  the  maiiwicE,  ovaries, 
or  testes  is  apt  to  occur,  when  the  symptoms  peculiar  to  such  affection 
will  be  added.  It  has  been  noted  that  a  continuance  of  the  tempera- 
ture after  the  decline  of  the  parotid  symptoms  has  begun,  usually  is 
significant  of  metastasis.  It  is  claimed  that  the  involvement  of  other 
organs  during  the  course  of  mumps  is  not  an  example  of  metastasis, 
but  a  true  transfer  of  the  disease. 

Diag'nosis.     An  error  seems  impossible. 

Prognosis.  Simple  mumps,  favorable ;  the  chief  danger  being 
from  the  altered  function  of  the  mammae,  ovary  or  testes  after 
metastasis. 

Treatment.  The  disease  being  self4imited,  the  indications  are 
entirely  symptomatic,  with  attention  to  the  secretions,  although  ex- 
tractiim  pilocarpi  fiiiidum,  rr^x-xxx,  repeated,  has  been  used  with 
varying  success  as  a  specific. 

Locally,  either  cold  or  warmth  to  the  affected  gland, whichever  is  most 
agreeable,  or  equal  parts  of  iingiientum  belladonjice  et  hydrargyrtim. 

If  the  swelling  shows  a  tendency  to  linger,  use  small  blisters  over 
the  part  and  administer  potassii  iodidum ;  if  suppuration  occur, 
evacuate  pus,  apply  poultices  and  administer  quinina. 

If  orchitis  occur,  the  use  of  the  belladonna  and  mercurial  ointment 
and  the   internal  use  of  potassii  iodidum. 


DIPHTHERIA. 

Synonyms.  Putrid  sore  throat ;  malignant  ulcerous  sore  throat ; 
malignant  quinsy;  membranous  angina. 

Definition.  An  acute,  specific,  constitutional  disease,  both  epi- 
demic and  contagious,  beginning  by  an  affection  of  the  throat,  char- 
acterized by  a  local  exudation  and  glandular  enlargements ;  attended 
with  great  prostration  of  the  vital  powers  and  albuminuria,  and  having 
for  its  sequelae  various  paralyses. 

Causes.  A  specific  poiso?i,  the  character  of  which  is  unknown. 
It  is  preeminently  a  disease  of  childhood.  It  is  apt  to  recur  in  those 
who  have  once  been  affected.  All  conditions  of  bad  hygiene  increase 
its  virulence  and  diffusion,  although  the  chief  cause  of  its  spread  is 
contagion. 


ACUTE  GENERAL  DISEASES.  145 

The  poison  exists  in  the  exudation  and  secretions  of  the  fauces  and 
in  the  breath,  and  floats  in  the  atmosphere  at  a  considerable  distance 
from  the  original  source. 

The  theory  of  "  No  bacteria,  no  diphtheria,"  is  not  proven. 

The  period  of  z7tcubation  is  from  three  to  five  days. 

Pathological  Anatomy.  The  diphtheritic  inflammation  differs 
from  either  the  croupous  or  catarrhal  form,  in  that  the  exudation  is  not 
only  upon,  but  also  'within,  the  substance  of  the  mucous  membrane. 

At  first  there  is  redness,  which  may  begin  in  any  part  of  the  throat, 
associated  with  swelling  and  an  increased  secretion  of  viscid  mucus. 
The  redness  spreads  over  the  entire  mucous  surface,  when  the  exuda- 
tion makes  its  appearance.  The  deposit  may  commence  from  one  or 
several  points,  such  as  one  tonsil,  the  soft  palate,  or  the  back  of  the 
fauces,  which,  however,  speedily  extend  and  coalesce,  forming  exten- 
sive patches,  or  cover  uniformly  the  entire  surface. 

The  patches  are  of  variable  thickness,  which  is  increased  by  suc- 
cessive layers  being  formed  underneath. 

The  color  is  usually  gray,  white  or  slightly  yellow,  but  may  be 
brownish  or  blackish,  the  consistence  ranging  from  "cream  to  wash 
leather." 

On  removing  the  membrane,  which  is  accomplished  with  more  or 
less  difficulty,  a  raw,  bleeding  surface  is  exposed,  and  at  times  an 
ulcer,  which  is  speedily  covered  with  a  fresh  deposit. 

If  the  exudation  separate  itself,  it  is  either  not  renewed  at  all  or 
only  in  thinner  films. 

The  exudation  of  membrane,  examined  by  the  microscope,  is 
composed  of  fibrin,  pus  corpuscles,  epithelial  granular  cells  and 
bacteria. 

If  the  larynx,  trachea,  or  nasal  mucous  membranes  participate  in 
the  disease,  the  croupous  and  not  the  diphtheritic  form  of  inflamma- 
tion occurs. 

T\iQ,  lymphatic  glands  of  the  neck,  whose  vessels  originate  in  the 
faucial  tissues,  are  enlarged  and  inflamed,  and  contain  large  numbers 
of  bacteria,  probably  originating  as  the  result  of  decomposition. 

The  muscular  tissue  of  the  heart  becomes  soft,  is  easily  torn,  and 
its  fibrillae  are  far  advanced  in  granular  degeneration.  Ulcerative 
endocarditis  has  been  frequently  observed. 

The  kidneys  undergo  a  granular  degeneration  in  severe  attacks. 

The  blood  undergoes  alteration,  being  black  and  fluid. 

12 


146  PRACTICE   OF   MEDICINE. 

Symptoms.  Following  the  law  oi  contagious  diseases,  the  symp- 
toms vary  in  intensity  in  different  cases,  the  prominent  symptoms 
being  often  disproportionate  to  the  gravity  of  the  attack. 

The  itivasioji  may  be  mild,  with  rigors  succeeded  by  moderate 
fever,  headache,  languor,  loss  of  appetite,  stiffness  of  the  neck,  tender- 
ness about  the  angles  of  the  jaw,  or  slight  soreness  of  the  throat. 

In  other  cases  the  invasion  is  more  abrupt  and  severe,  with  chilli- 
ness followed  by  %xq.2X  febrile  reaction,  103°  to  105°  Y .,  pain  in  the 
ear,  achi?tg  of  the  limbs,  loss  of  strejigth,  paiiiful  deglutitioft  and 
swelliftg  of  the  ?teck,  compelling  the  patient  to  take  to  bed  from  the 
onset. 

The  appetite  is  poor,  the  tongue  slightly  coated,  sometimes  more 
or  less  exudation  appearing  upon  it,  the  bowels  being  either  regular 
or  slightly  relaxed.  Th.Q  pulse,  at  first  full  and  strong,  soon  becomes 
either  frequent  or  slow,  but  compressible.  The  uritie  is  scanty,  high 
colored  and  contains  albumin. 

The  /(?rrt/ symptoms  in  the  majority  of  cases  are  associated  with  the 
throat.  The  patient  complains  of  a  frequent  and  persistent  desire  to 
hawk,  in  order  to  clear  the  throat.  On  inspection  the  fauces  are  seen 
red  and  swollen  and  more  or  less  covered  with  the  diphtheritic  exu- 
dation ;  sometimes  the  tonsils  and  tivula  are  greatly  swollen  and 
spotted  with  exudation.  In  bad  cases,  more  or  less  ulceration  or 
sloughing  may  be  observed.  Not  unfrequently  fragments  of  exuda- 
tion, \kv^  false  membrane,  are  expectorated,  with  particles  of  the  ulcer- 
ated tissues,  having  an  offe7isive  odor,  which  is  transmitted  to  the 
breath.  The  lymphatic  glands  of  the  neck  are  enlarged  and  tender ^ 
and  in  severe  cases  the  tissues  of  the  neck  are  greatly  tumefied. 

Extension  to  the  nasal  cavities  causes  a  sanious  and  offensive  dis- 
charge from  the  nose,  with  attacks  of  epistaxis. 

Extension  to  the  larynx  is  indicated  by  hoarseness  or  complete  loss 
of  voice,  croupy  cough  and  obstructive  dyspnoea,  which  often  become 
urgent,  the  breathing  being  7ioisy  and  stridulous,  and  subject  to  par- 
oxysmal exacerbations.  If  the  inflammation  extend  to  the  bronchi, 
the  breathing  becomes  still  more  embarrassed. 

Duration.  Ranges  from  two  to  fourteen  days,  an  average  being 
about  nine  days,  although  complications  and  sequelae  may  prolong 
its  course. 

Relapses  are  not  uncommon. 

Sequelae.     Those  who  recover  from  a  severe  attack  remain  often 


ACUTE  GENERAL'  DISEASES.  147 

for  weeks  with  a  pale  and  cachectic  appearance,  due  to  the  profound 
blood  alteration. 

Paralysis  is  a  common  sequelae,  following  the  mild  as  often  as  the 
severe  attacks.  Usually  not  occurring  until  the  patient  seems  fully 
convalescent. 

Pharyngeal  paralysis  is  the  most  common,  causing  difficulty  or  in- 
ability of  deglutition,  fluids  regurgitating  through  the  nose. 

Cardiac  paralysis  is  not  unfrequent,  the  pulsations  descending  to 
60,  50,  40,  and  in  a  case  seen  by  the  author,  to  20  per  minute. 

Diphtheritic  paralysis  may  affect  the  motor  muscles  of  the  eye, 
causing  strabismus  ;  the  muscles  of  one  side,  hemiplegia  ;  of  the  legs, 
paraplegia ;  and  of  the  bladder,  leading  to  retetition  of  tirine  or 
difficulty  in  passing  it. 

Sensation  is  also  diminished  in  the  paralyzed  parts. 

Diagnosis.  From  follicular  ulcer atio7i  of  the  tonsils,  which  is 
frequently  termed  diphtheria,  by  the  shght  or  absent  systemic 
symptoms,  the  ulcerated  condition  being  limited  to  the  tonsils, 
but  often  one,  and  the  absence  of  glandular  enlargement  and  fol- 
lowing palsies. 

Yrom  pharyngitis,  by  the  absence  of  exudation  and  loss  of  faucial 
tissue  and  constitutional  symptoms. 

From  scarlatina,  by  the  presence  of  the  eruption  and  the  absence 
of  membrane  in  the  fauces. 

From  membranous  croup,  by  the  difference  in  the  constitutional 
symptoms ;  croup  appears  sporadically  and  is  not  contagious,  diph- 
theria being  highly  contagious  and  frequently  occurs  in  epidemics  ; 
in  diphtheria  of  the  larynx,  the  depression  is  clearly  that  of  blood 
poisoning,  while  in  croup,  the  depression  is  in  proportion  to  the  me- 
chanical obstruction  of  the  respiration  by  the  membranous  exudation. 
The  pathology  of  croup  is  simple  and  easy  of  investigation  ;  diph- 
theria is  obscure  in  its  etiology  and  progress.  The  temperature  record 
of  croup  is  a  high  one  until  carbonic  acid  poisoning  is  imminent  from 
the  mechanical  obstruction  of  respiration,  while  in  diphtheria,  the 
tendency  to  a  decline  in  the  temperature  after  the  second  day  is 
nearly  characteristic,  regardless  of  the  amount  of  laryngeal  obstruc- 
tion. In  croup  the  pharynx  contains  no  membrane,  and  is  but 
slightly,  if  at  all,  inflamed,  and  associated  trouble  in  the  nose  is  of  the 
rarest  occurrence,  the  very  reverse  obtaining  in  diphtheria.  In  croup 
the   laryngeal    symptoms    are   from   the    onset,   while   in   laryngeal 


14S  PRACTICE   OF   MEDICINE. 

diphtheria  the  pharyngeal  symptoms  almost  always  precede.  In  croup 
glandular  involvement  is  a  clinical  novelty,  as  are  subsequent  palsies, 
while  glandular  involvement  and  various  palsies  are  the  rule  in 
diphtheria.  Albuminuria  is  the  rule  in  diphtheria,  seldom  occurring 
in  croup. 

Prognosis.  Always  grave,  but  more  so  in  children  than  in  adults. 
Its  gravity,  in  the  majority  of  cases,  is  proportionate  to  the  local 
symptoms.     The  average  mortality  is  about  ten  per  cent. 

Favorable  indications  are,  moderate  fever,  strength  slightly  im- 
paired, a  good  constitution,  and  moderate  exudation. 

Unfavorable  indications  are,  great  depression,  spreading  exudation, 
great  swelling  of  the  cervical  glands,  large  amount  of  albumin,  exten- 
sion to  larynx  and  nasal  mucous  membranes,  hemorrhages  from  the 
fauces  and  nose,  and  an  epidemic  character. 

Treatment.  No  specific  plan  of  medication  has  been  found  uni- 
formly successful.  It  is  a  disease  of  debihty.  The  blood  being  more 
or  less  altered,  it  follows  that  sustaitiing  measures  should  be  resorted 
to  in  all  cases. 

The  diet  should  be  of  the  most  nutritious  character  from  the  onset, 
with  such  articles  as  milk,  eggs,  broths  and  oysters,  at  intervals  of 
every  two  or  three  hotirs.  If  deglutition  be  too  painful,  resort  must  be 
had  to  nutritious  enemata,  the  following  being  a  suitable  formula  : — 

R.     Milk, f^j 

Spts.  frumenti, f^iv 

Egg, One.  M. 

SiG. — Little  salt  added,  beaten  up  and  warmed. 

Stimulants  should  be  used  boldly  from  the  onset,  guiding  the  dose 
by  the  effect ;  usually,  a  child  of  two  years  requires  from  thirty  to  sixty 
miiiims  o{  spiritus  vini gallici  or  spiritus  frinne7iti,  every  two  or  three 
hours  ;  an  adult  from  two  iofour  drachms  every  three  hours. 

Ferrian  and  potassii  chloras,  m  full  doses,  frequently  repeated,  have 
seemed,  when  begun  early  in  the  attack,  to  modify  the  course  of  the 
malady,  and  they  have  the  additional  advantage  of  acting  locally 
upon  the  throat  as  they  are  swallowed.     A  good  formula  is : — 

IJ.     Tinct.  ferri  chlor., gtt.  v-x-xx 

Potassii  chlor., gr.  iij-v 

Glycerini, f^ss 

Syr.  zingib., ad f.^j-ij-  M. 

SiG. — In  water  every  three  hours,  for  a  child  of  two  or  three  years. 


ACUTE  GENERAL  DISEASES.  149 

The  efficacy  of  the  above  is  greatly  enhanced,  in  the  author's  expe- 
rience, by  the  addition  to  each  dose  oi  tinctura  belladonncE,  gtt.j-v. 

Quinina,  gr.  xvj-xxiv  per  day  for  a  young  adult,  and  gr.  v-x  for 
a  child,  should  be  used  throughout  the  disease ;  if  irritability  of  the 
stomach  prevent  its  administration  by  the  mouth,  it  can  be  used  as  a 
suppository  or  locally  in  the  form  of  the  oleate. 

Calomel  in  small  doses,  combined  with  sodii  bicarbonas  every  hour 
until  the  breath  becomes  fetid,  is  beneficial,  and  especially  in  cases 
showing  a  tendency  to  spread  towards  the  larynx.  Indeed,  a  tolerance 
to  calomel  seems  to  exist  in  dipht?i,eria  of  the  larynx. 

Hydrarg.  chlor.  corros.,  gr.  -^g— ^,  repeated  every  second  or  third 
hour,  also  acts  well  in  many  cases,  combined  as  follows : — 

^.      Hydrargyrichlorid.  corros iv., g^- ?V 

Tinct,  ferri  chlorid., Tl^v-x 

Glycerini,    . , TT\^x 

Aquae, ad 3j.  M. 

SiG. — One  teaspoonful  every  hour  or  two,  well  diluted. 

Locally.  Cleanliness  of  the  fauces  is  of  the  utmost  importance,  and 
if  a  non-irritating  disinfectant  be  added,  its  value  is  enhanced.  Prof. 
Bartholow  "  has  seen  excellent  results  from  the  frequent  application 
of  a  solution  of  acidum  lacticum,  strong  enough  to  taste  sour,  by  means 
of  a  mop."  The  following,  used  as  3.  gargle,  or  applied  by  a  mop,  is 
useful : — 

R  .     Acid,  salicyl., gr.  xx 

Glycerini, f5j 

Aquae  destil,, f^iij-  M. 

Or— 

Be .     Potass,  chloras, ^  iv. 

Acid,  carbol., gr.  ij-iv. 

Tinct.  myrrh., ?j 

Inf.  cinchonse, gij.  M. 

Or— 

B:.     Ext.  pancreatis, ^j 

Sodii  bicarb., giij.  M. 

SiG. — Add  3J  to  aquae  gvj,  and  apply  with  camel's-hair  pencil. 

Inhalations  of  steam  and  hot  water,  and  allowing  the  patient  to 
suck  pellets  of  ice,  give  relief.  Sponges  dipped  in  hot  water  and 
applied  to  the  angles  of  the  jaw  are  beneficial. 

For  laryngeal  diphtheria  the  same  general  treatment,  especially  the 


150  PRACTICE  OF  MEDICINE. 

mercurial,  with  inhalations  of  lime  by  slaking  freshly -burned  lime  in  a 
vessel  and  directing  the  vapor  to  the  child  by  a  newspaper,  or  some 
similar  contrivance,  or  using  three  parts  of  liquor  calcis  and  one  part 
oi  glycerin,  in  an  atomizer,  every  half  hour  or  hour,  or  liq.  trypsin, 
as  a  spray.  If  these  means  fail,  resort  must  be  had  to  tracheotomy, 
or  intubation  of  the  larynx,  which  have  succeeded  in  many  desperate 
cases. 

For  nasal  diphtheria,  the  same  general  treatment,  and  syringing  the 
nose  every  two  or  three  hours  with  a  weak  solution  potassii  chloras, 
or  acidum  carbolicu?n,  or  the  following  : — 

R.     Sodii  sulphit., ^iij 

Glycerini, f^ij 

Aquse,      f^iv-  M- 

For  the  paralysis,  strychttina  and  ferrum  internally,  or  strychnina 
hypodermically,  with  the  galvanic  or  faradic  current  locally. 


ACUTE  ARTICULAR  RHEUMATISM. 

Synon3niis.     Rheumatic  fever  ;  inflammatory  rheumatism. 

Definition.  A  constitutional  disease,  characterized  by  fever,  in- 
flammation in  and  around  the  joints,  occurring  in  suc<:ession,  and  a 
great  tendency  to  inflammation  of  either  the  endocardium  or  peri- 
cardium. 

Causes.  T\i^  predisposing  causes  are  inherited  tendency,  scarla- 
tina, and  the  puerperal  state. 

The  exciting  causes,  exposure  to  cold  and  chilling  of  the  body. 
Rheumatism  rarely  occurs  before  seven  or  after  fifty  years.  The 
liability  to  the  disease  is  increased  by  having  had  an  attack. 

Pathological  Anatomy.  The  blood  contains  an  excess  of 
lactic  acid.  The  joijits  bear  the  brunt  of  the  attack  ;  the  synovial 
membrane  is  reddened,  the  vascularity  of  the  synovial  fringes  is 
increased,  so  with  the  synovial  fluid,  which  is  thinner,  of  a  reddish 
color,  containing  some  gelatinous  coagula  of  fibrin,  and  under  the 
microscope  nucleated  cells,  ordinary  pus  cells  being  rarely  seen. 

The  swelling  visible  about  the  affected  part  depends  mostly  on 
inflammatory  oedema  of  the  connective  tissue  around  the  joint. 

The /am  is  probably  due,  in  all  cases,  to  stretching  of  and  pressure 
on  the  elements  of  the  tissues  by  the  dilated  capillaries  and  the  inflam- 


ACUTE   GENERAL   DISEASES.  151 

matory  oedema.  For  the  changes  which  ensue  when  the  endo-  and 
pericardium  are  attacked,  the  reader  is  referred  to  the  sections  on 
those  diseases. 

Syraptoms.  Begins  suddenly,  generally  at  night,  with  a  chill  or 
chilliness,  pam  and  stiffness  in  the  joints,  loss  of  appetite,  at  times, 
nausea  and  vomiting,  followed  hy  fever,  the  temperature  soon  reach- 
ing 102°,  F.,  to  104°.  in  rare  cases  108°  to  110°  {the  hyperpyrexia),  the 
pulse  seldom  exceeding  c)^,  great  thirst,  profuse  acid  sweats,  scanty, 
high  colored,  acid  urine,  at  times  showing  traces  of  albumin,  the 
bowels  constipated.  The  fever  continues  throughout  the  attack,  show- 
ing marked  remissions.  Delirium  is  absent,  except  the  hyperpyrexia 
occur.  Sleep  is  prevented  by  the  pain  and  the  "proinso.  perspirations. 
The  strength  is  moderately  well  preserved. 

The  skin  is  often  covered  with  an  eruption  of  miliaria  rubra,  red 
papulce  and  miliaria  alba,  the  result  of  irritation  at  the  orifices  of  the 
perspiratory  glands,  from  the  excessive  sweating. 

The  local  phenomena  are  pain,  tenderness,  increased  heat,  swelling 
and  redness  of  one  or  m.ore  joints;  if  but  one  joint,  it  is  termed 
monoarthritis,  if  more  than  one,  polyarthritis.  Pain  is  aggravated 
by  motion  and  pressure.  Swelling  is  most  apparent  in  those  joints 
not  covered  with  muscle,  to  wit :  knee,  wrist,  elbow,  ankle,  and  the 
hands  and  feet,  and  is  proportionate  to  the  acuteness  of  the  attack. 
The  inflammation  may  abruptly  cease  at  one  or  more  joints,  and  as 
suddenly  attack  others. 

The  disease  is  extremely  irregular  as  regards  the  number  of  joints 
affected,  although  the  local  manifestations  are  controlled  by  an  im- 
portant pathological  law,  to  wit :  the  law  of  parallelism.  Correspond- 
ing joints  are  often  affected  together,  and  when  not,  the  different 
affected  joints  are  either  on  one  side  of  the  body  or  those  on  both 
sides  which  are  analogous,  as,  the  knee,  elbow,  wrist,  ankle,  hip  and 
shoulder,  are  attacked  together. 

Complications.  Pericarditis,  endocarditis,  myocarditis,  cerebral 
endarteritis,  bronchitis,  pneumonitis  and  pleuritis. 

Duration.  The  duration  of  acute  rheumatism  is  governed  entirely 
by  the  presence  or  absence  of  complications.  Uncomplicated  cases 
recover  in  from  thirteen  to  twenty-one  days,  although  they  may  be 
prolonged  to  five  or  six  weeks.     Relapses  are  frequent. 

Diagnosis.     A   typical  case   cannot  be  mistaken  for  any  other 


152  PRACTICE   OF   MEDICINE. 

disease,  but  cases  running  a  subacute  course  may  be  mistaken  for 
acute  rheumatoid  arthritis,  gonorrhoeal  rheumatism,  or  pyaemia. 

Acute  rheumatoid  arthritis  attacks  one  joint  at  a  time  and  becomes 
permanent,  has  shght  if  any  fever,  no  sweats  or  cardiac  lesions. 

Gonorrhccal  rheinnatisjn  is  associated  with  a  gleety  discharge, 
attacks  either  the  ankle  or  wrist  only,  is  slowly  influenced  by  treat- 
ment, and  lacks  the  febrile  phenomena. 

Pycsmia  is  usually  manifested  at  a  single  joint  at  the  time,  and  is 
followed  by  suppuration  and  all  the  symptoms  of  hectic  fever. 

Prognosis.  Recovery  is  the  rule  in  uncomplicated  cases,  the 
mortality  being  about  three  per  cent.  When  death  occurs  it  usually 
depends  upon  hyperpyrexia,  cardiac  complication,  or  cerebral  end- 
arteritis. 

Treatment.  Owing  to  our  imperfect  knowledge  of  the  exact 
nature  of  this  most  painful  disease,  its  treatment  still  remains  either 
empirical  or  is  directed  toward  certain  prominent  symptoms  or  com- 
plications of  the  disease.  Garrod  claims  that  "colored  water"  is 
about  as  potent  as  anything  else,  for  it  is,  he  says,  a  "  self-limited 
disease,"  sometimes  running  a  long  and  sometimes  a  short  course. 
Rest  in  bed,  whether  the  pain  forces  it  or  not,  is  imperative.  Warmth 
is  as  imperative,  for  which  purpose  the  patient  should  be  kept  in 
blankets — no  sheets — and  wear  woolen  garments.  The  diet  should 
be  easily  digested  food,  milk  being  the  most  suitable. 

Strong  and  vigorous  patients  do  well  with  acidum  salicylicum  or 
the  salicylates  in  large  and  frequently  repeated  doses,  to  wit : — 

R .     Acidi  salicylici, gr-  xx 

Liq.  ammonii  acetat., f^iss 

Spts.  setheris  nitrosi 'n\^xx 

Syr.  simplicis, TT\,xv. 

Every  three  hours,  well  diluted. 

Or— 

U.     Sodii  salicyl., 5^j 

Sodii  bicarb., ^iv 

Aq.  menth.  pip., ftij 

Aq.  destillat., f^ij.  M. 

SiG. — One  teaspoonful  every  three  or  four  hours.     Omit  the  soda  as 
soon  as  urine  becomes  alkaline. 

If  benefit  follows,  the  evidence  is  quickly  afforded  in  the  relief  of  pain 


ACUTE  GENERAL  DISEASES.  153 

and  the  decline  of  the  temperature  and  swelling.  If,  therefore,  after 
three  or  four  days'  use  of  the  salicylates  or  acidum  salicylicum,  as 
above  recommended,  signs  of  improvement  are  wanting,  the  treat- 
ment had  better  be  changed  for  the  a/ka/ine  tresitvaent,  which  consists 
in  the  administration  of  an  ounce  and  a  half  of  the  alkaline  carbon- 
ates, either  alone  or  v/ith  a  vegetable  acid,  each  twenty-four  hours, 
until  the  uritie  becomes  tieiitral  or  alkaline,  when  the  quantity  is 
reduced  to  an  amount  sufficient  to  maintain  alkaline  urine,  to  wit : — 

R .     Potassii  bicarbonatis, ^  ij 

Acid,  tartaric, gr.  xxx. 

Dissolved  in  a  glass  of  water  and  drank  effervescing,  every  three  hours. 
Or— 

U .     Potass,  bicarb. , 'T^'x] 

Succi  limonis, f  .^  iv 

Aquae  cinnamomi, aa f  J  ss.  M. 

SiG. — In  water,  every  three  hours. 

After  the  more  acute  symptoms  are  passed,  change  either  of  the  above 
for  tinct.  ferri chlor.,  gtt.  xx,  every  four  hours,  well  diluted,  or  full  doses 
of  Basham's  mixture. 

Pale,  feeble  and  anaemic  patients,  or  attacks  following  scarlatina, 
are  most  favorable  influenced  with — 

R  .     Tinct.  ferri  chlor., git.  xx-xxx 

Syr.  limonis, gtt.  xx 

Aquae, aa f^j.  M. 

SiG. — Every  four  hours,  in  a  glass  of  water. 
Or— 

R.     Acid,  salicylic!, 9^'j 

Ferri  pyrophos., ^  iv 

Sodii  phosphat., ^^iij 

Aquce  font., f^ij-  M- 

SiG. — Dessertspoonful  every  three  or  four  hours. 

Prof.  DaCosta  reports  a  lessened  proportion  of  cardiac  complica- 
tions with  amjnonii  bromidwn,  gr.  xv-xx,  every  four  hours. 

Subacute  attacks  and  lingering  cases  are  favorably  influenced  by 

R  .     Lithii  salicylatis, gr.  xv-xx 

Syr.  zingiberis, f^j 

Aq.  lauro  cerasi, f^j.  M, 

Every  four  hours. 

13 


1d4  practice  of  medicine. 

Good  results  follow,  in  a  fair  number  of  cases,  sa/ol,  gr.  v-x,  every 
four  hours,  also  from  aiitipyrine ,  gr.  xv,  every  three  or  four  hours. 

Whichever  plan,  acidum  salicylicum,  salicylates,  alkaline  or  ferrum, 
is  adopted,  quiniiia,  gr.  xij-xx,  per  day,  should  also  be  used. 

Pain  and  restlessness  should  be  controlled  by  opium  in  some  form, 
in  full  doses,  or  atropitia,  gr.  g^^,  hypodermically. 

For  the  hyperpyrexia,  guifii7ta,  gr.  xxx-lx,  repeated  p.  r.  n.,  with  the 
cold  bath  or  wet  pack. 

Locally,  the  affected  joints  should  be  wrapped  in  cotton-wool  or 
flannel,  saturated  with  a  solution  of  tiftctiira  opii,  one  part,  and  liq. 
phitnb.  subacetat.  dil,  two  parts,  or — 

R.     Sodii  bicarbonatis, 5ij 

Tinct.  opii, ^5^5 

Aquce  bul., Oij.  M. 

Dr.  Bartholow  finds  the  application  of  blisters  an  effective  method. 
He  says,  "  I  have  small  blisters,  the  size  of  a  silver  dollar,  placed 
around  the  joint,  leaving  an  interval  between  for  succeeding  applica- 
tions. It  is  by  no  means  so  painful  and  disagreeable  as  it  appears  at 
first  sight.  The  blisters  remarkably  relieve  the  pain,  bring  about  a 
more  alkaline  condition  of  the  blood,  and  render  the  urine  less  acid, 
or  bring  it  to  neutral,  or  even  to  alkaline." 

The  complications  are  to  be  treated  according  to  their  character. 


MUSCULAR  RHEUMATISM. 

Synonyms.  According  to  location,  to  wit:  cephalodynia  ;  lum- 
bago ;  torticollis  ;  pleurodynia. 

Definition.  An  affection  of  the  voluntary  muscles,  inflammatory 
in  character,  either  acute  or  chronic ;  characterized  by  pain,  tender- 
ness, and  stiffness  of  the  affected  muscles.  It  is  never  complicated 
with  cardiac  disease. 

Causes.  A  disease  of  adult  life.  One  attack  predisposes  to  another. 
Almost  always  due  to  cold  and  damp,  or  direct  draughts  of  cold  air. 
Gout  increases  the  tendency  to  attacks. 

Pathological  Anatomy.  The  true  nature  of  muscular  rheuma- 
tism is  not  yet  determined.  Virchow  suggests  a  "  hypersemia  of,  and 
scanty  serous  exudation  between,  the  muscular  striae,  and  in  chronic 
cases  inflammatory  proliferation  of  the  connective  tissue." 


ACUTE   GENERAL   DISEASES.  155 

Symptoms.  The  first  attack  is  generally  acute.  Onset  rather 
sudden,  W\\\i  pain  in  the  affected  muscles,  with  slight  tefiderness,  and 
considerable  stiffness,  and  difiiczilty  of  movement,  by  which  also  the 
pain  is  increased. 

The  suffering  may  be  severe  and  constant,  or  only  on  motion. 
Spasm  of  the  affected  muscles  may  occur.  Objective  symptoms  are 
wanting,  except  it  is  evident  that  the  patient  keeps  the  affected 
muscles  as  quiet  as  possible.  Fever  is  absent.  The  pain  may  pre- 
vent sleep. 

Duratio7i,  acute  form,  about  one  week.  C//r^«zV  returns  frequently, 
and  finally  becomes  constant  and  aggravated  when  the  weather  is 
damp. 

Varieties.  It  may  affect  any  or  all  of  the  voluntary  muscles,  but 
its  most  frequent  and  important  varieties  are  : — 

1.  Cephalodynia.  Situated  in  the  occipito-frontal muscles.  Distin- 
guished from  neuralgia  of  the  trifacial,  or  occipital  nerve,  by  pain  on 
both  sides  of  the  head,  excited  or  aggravated  by  movements  of  the 
muscle,  and  by  absence  of  disseminated  points  of  tenderness. 

The  muscles  of  the  eye  may  be  affected,  and  movements  of  that 
organ  excite  pain.  If  the  temporal  and  masseter  muscles  are  at- 
tacked, mastication  excites  pain. 

2.  Torticollis.  Wry  neck,  or  stiff  neck.  Situated  in  the  sterno- 
mastoid  muscles.  Generally  limited  to  one  side  of  the  neck,  toward 
which  side  the  head  is  twisted,  great  pain  being  excited  on  attempt- 
ing to  turn  to  the  opposite  side.  Rheumatism  of  the  muscles  of  the 
back  of  the  neck,  cervicodynia,  may  be  mistaken  for  occipital  neu- 
ralgia. 

3.  Pleurodynia.  Situated  in  the  thoracic  muscles,  and  may  be 
mistaken  for  pleuritis,  or  intercostal  neuralgia,  from  which  it  is  differ- 
entiated by  the  absence  of  the  diagnostic  features  of  each.  Pain  is 
excited  by  forced  breathing,  coughing  and  sneezing. 

4.  Lumbodynia  or  lumbago.  Situated  in  the  mass  of  muscles  and 
fasciae  which  occupy  the  lumbar  region.  Most  common  variety. 
Usually  affects  both  sides.  It  may  set  in  rapidly  and  become  very 
severe.  Motion  of  any  kind  aggravates  the  pain,  often  becoming 
very  sharp  or  stabbing  in  character.  It  is  sometimes  complicated 
with  acute  sciatica,  when  the  suffering  is  agonizing. 

Diagnosis.  The  different  varieties  may  be  mistaken  for  any  of 
the    following    ailments,   to  wit :    trifacial,    occipital    or   intercostal 


156  PRACTICE  OF   MEDICINE. 

neuralgia,  pains  of  progressive  muscular  atrophy,  syphilis,  metallic 
poisons,  or  painful  affections  of  the  loins,  arising  from  calculi  or 
gravel  in  the  kidney. 

A  careful  examination  of  the  history  is  usually  sufficient  to  arrive 
at  a  correct  diagnosis. 

Prognosis.  Difficult  to  eradicate,  and  in  chronic  cases  to  amelio- 
rate ;  but  it  is  not  dangerous  to  life.     Death  never  results. 

Treatment.  Rest  is  the  first  indication.  This  is  accomplished 
in  pieurody}iia  by  firmly  strapping  the  affected  side  with  broad  strips 
of  plaster,  extending  from  mid-spine  to  mid-sternum. 

The  local  application  to  the  affected  muscles  of  hot  poultices,  made 
of  two-thirds  pilocarpicslQdiWQS,  and  one.-th\r<l  flaxseed  meal,  changing 
them  every  two  hours,  is,  in  the  opinion  of  the  author,  the  most 
rapidly  successful  treatment  in  acute  cases. 

Internally,  sodii  salicylat.,  gr.  xv-xx,  every  two  or  three  hours,  is  a 
most  valuable  remedy.  Prof.  Bartholow  declares  that  lithii  brojnidujti 
is  almost  a  specific  in  muscular  rheumatism. 

For  the/«m,  and  consequent  sleeplessness,  use — 

li  .     Pulv.  ipecac  et  opii, gf-  x 

Potass,  nitras, gr.  v-x.  M. 

SiG. — In  powder,  morning  and  night. 

Or,  hypodermically,  at  the  seat  of  pain,  morphina,  gr.  >^-X.  ^i^^ 
atropina,  gr.  ■^,  p.  r.  n. 

The  following  liniment  is  valuable  in  many  cases  : — 

K.     Quininae  salph., gr- xl 

Ol.  gaultherire, f 5j 

Lin.  saponis  CO., •  f^iij-  M. 

SiG. — Thoroughly  applied  several  times  a  day. 

In  attacks  where  the  disease  is  limited  to  a  few  muscles,  the  follow- 
ing liniment  is  valuable  : — 

R  .     Chloral  hydrat., 

Camphorse, aa gss. 

M.  et  adde 

Lanoline, '5].  M. 

SlG. — Apply  locally. 

Chronic  cases  :  Rest,  flannel  worn  next  to  the  skin,  stimulating  and 
anodyne  liniment,  mild  galvanism,  dry   heat,  as    ironing  over   the 


ACUTE   GENERAL   DISEASES.  157 

affected  part  with  a  common  flat-iron,   a  piece   of  paper   or   towel 
being  placed  next  to  the  skin. 

Internally,  potassii  iodidum,  ammonii  murias,  sulphur,  guaiacuin, 
or  arsetiiciini,  variously  combined. 


RHEUMATOID  ARTHRITIS. 

Synonyms.     Arthritis  deformans  ;  rheumatic  gout. 

Definition.  An  inflammation  of  the  joints,  accompanied  with 
but  slight  fever,  without  suppuration,  progressive  in  character,  causing 
nearly  symmetrical  enlargement  and  deformity  of  various  articula- 
tions. 

Causes.  More  common  in  females  than  in  males,  and  in  the 
weak  and  anaemic.  Among  the  causes  are  bad  hygiene,  exposure, 
prolonged  lactation,  frequent  pregnancies,  .menopause,  grief,  tuber- 
cular diathesis,  and  following  attacks  of  articular  rheumatism. 

Pathological  Anatomy.  It  is  not  rheumatism,  as  the  blood 
contains  no  lactic  acid.  It  is  not  gout,  as  uric  acid  is  not  found  in  the 
blood  nor  urate  of  soditcm  in  the  joints. 

At  first  rheumatoid  arthritis  is  attended  with  hypersemia  of  the 
affected  synovial  membrane  and  increase  of  the  synovial  fluid.  Soon 
the  capsular  ligament  becomes  irregularly  thickened,  the  synovial 
fluid  decreasing.  If  the  process  continue,  the  internal  ligament  is 
destroyed,  thus  allowing  dislocations  to  occur.  The  inter-articular 
fibro-cartilages  ulcerate  and  disappear,  as  do  the  cartilages  covering 
the  ends  of  the  bones,  the  ends  of  the  bones  becoming  smooth  and 
eburnated,  and  often  greatly  enlarged. 

Symptoms.     Either  acute  or  chronic,  the  latter  most  common. 

Acute  form  involves  several  joints  atthe  same  time,  and  is  attended 
with  slight  pyrexia. 

Chronic  form  slowly  involves  one  joint,  which  seemingly  soon 
recovers,  and  is  attacked  again,  and  may  never  recover,  but  grows 
progressively  worse. 

'  The  joint  slowly  enlarges,  is  painful,  movement  exciting  neuralgic 
pains  along  the  limb.  Soon  the  articulation  becomes  rigid  or  slightly 
movable  after  prolonged  attempts.  Redness  and  tenderness  are 
wanting.  Crepitatio7i  is  distinct  after  ulceration  has  destroyed  the 
cartilage. 


158  PRACTICE   OF   MEDICINE. 

The  hands  are  first  involved,  the  disease  spreading  symmetrically 
from  articulation  to  articulation,  until  in  severe  cases  every  joint  is 
deformed. 

Diagnosis.  Chro7iic  articular  rheumatism  is  often  confounded 
with  rheumatoid  arthritis  ;  but  the  former  lacks  the  marked  structural 
changes  and  the  progressive  involvement  of  joint  after  joint. 

Gout  differs  from  rheumatoid  arthritis  by  the  presence  of  deposits 
of  urate  of  sodium  in  the  joints,  the  ears,  tips  of  fingers  and  the 
bursae  over  the  olecranon  process  of  the  elbow,  the  presence  of  uric 
acid  in  the  blood,  and  the  decided  history  of  acute  paroxysms. 

Gonorrhceal  rheumatism,  so-called,  has  symptoms  akin  to  rheu- 
matoid arthritis,  but  the  history  of  urethral  suppuration  clears  up  the 
diagnosis. 

Paralysis  agiians,  when  pronounced,  might  be  confounded  with 
rheumatoid  arthritis,  if  the  examination  were  limited  to  the  joints, 
but  the  whole  history,  such  as  the  tremor,  the  gait,  etc.,  should  pre- 
vent error. 

Prognosis.  If  early  treatment  be  instituted,  the  disease  may  be 
held  in  abeyance  for  several  years.  After  pronounced  structural 
changes  have  begun,  the  malady  is  incurable,  although  it  may 
remain  stationary  for  a  long  time. 

Treatment.  If  treatment  be  instituted  before  serious  structural 
lesions  have  occurred,  the  author  has  seen  benefit  in  many  cases  by 
the  following  treatment  :  Oleum  morrhuoe  carefully  and  thoroughly 
rubbed  into  the  affected  joints,  three  times  a  day,  with  the  internal 
use  of  lithii  citras  effervescetites,  3j,  three  times  a  day,  and  the  follow- 
ing tonic  mixture  : — 

5c.     Massse  ferri  carbonat., gr.  v 

Liquor,  potass,  arsenit., TT^  v 

Vini  xerici, .^j 

Aquoe, 3J.  M. 

After  meals,  well  diluted. 

Sodii  salicylicum  is  recommended  early  in  the  disease. 

Complete  recoveries  are  reported  from  the  long-continued  admin- 
istration in  small  doses  of  liqicoris  potassii  arseiiilis. 

Attention  to  diet  and  hygiene  are  also  necessary.  When  structural 
changes  have  destroyed  portions  of  the  joint,  palliative  treatment  is 
the  only  indication. 


ACUTE   GENERAL   DISEASES.  159 

GOUT. 

Synonyms.  Podagra,  gout  in  the  foot;  chiragra,  the  hand; 
gonagra,  the  knee. 

Definition.  A  constitutional  disease,  usually  inherited;  charac- 
terized by  the  sudden  occurrence  of  a  paroxysm  of  severe  pain  and 
swelling  in  one  of  the  smaller  joints — the  great  toe  usually — with  the 
presence  of  uric  acid  in  the  blood,  and  the  deposit  of  the  urate  of 
sodium  in  the  structure  of  the  joint. 

Causes.  Predisposing ;  inherited ;  male  more  than  female — 
women  after  menopause. 

Exciting.  Malt  liquor  and  wine  drinking,  whether  male  or  female ; 
large  consumption  of  animal  food  ;  lead  poisoning  ;  winter  season. 

When  inherited  tendency,  may  begin  early  in  life ;  when  acquired 
tendency,  after  thirty-five  years. 

The  pathological  cause  consists  in  the  presence  of  an  excess  of  uric 
acid  in  the  blood,  in  the  form  of  urate  of  sodium. 

Pathological  Anatomy.  Gout  is  characterized  by  the  deposit 
of  urate  of  sodium  from  the  blood  into  the  structure  of  joints  and 
tissues  that  are  not  very  vascular.  The  deposit  is  associated  with 
signs  of  inflammation,  to  wit:  hyperemia,  redness  of  the  surface, 
with  swelling  and  effusion  in  and  around  the  affected  joint.  The 
surfaces  of  the  joint  are  incrusted  with  chalk-like  masses,  consisting 
of  urates,  which  become  greater  with  each  attack,  finally  causing 
great  deformity. 

The  deposit  usually  begins  in  the  metatarso-phalangeal  joint  of  the 
great  toe,  but  other  and  many  joints  are  soon  affected. 

The  deposit  may  also  be  found  in  the  knuckles,  eyelids,  and  car- 
tilages of  the  ear. 

"  Crystals  of  urate  of  soda  are  deposited  in  the  tubules  and  intra- 
tubular  tissues  "  of  the  kidneys — "  gouty  kidney  " — and  may  be  seen 
by  the  naked  eye,  the  kidneys  becoming  small,  granular  and  fibrous. 

Hypertrophy  of  the  left  ventricle  and  of  the  arteries,  ending  in 
atheromatous  changes,  are  results  of  gout. 

Symptoms.  Acute  gout  is  rare  in  the  United  States.  It  occurs 
in  paroxysms  ;  one  year's  interval  between  the  first  and  second 
attack  ;  six  months  usually  between  the  second  and  third,  after  which 
it  may  occur  at  any  time. 

Prodromes  usually  precede  the  paroxysm  for  several  days,  to  wit : 
acid  dyspepsia,  constipation,  headache  and  lassitude. 


160  PRACTICE   OF   MEDICINE. 

The  paroxysm  begins  suddenly,  between  midnight  and  2  a.m., 
with  acute  paiti  in  the  ball  of  the  great  toe,  which  becomes  red, 
hot,  sivollen,  and  so  sefisitive  that  the  slightest  touch  cannot  be 
borne. 

The  veins  are  filled,  the  foot,  ankle  and  leg  swollen,  and  the  limb 
the  seat  of  sudden  spasmodic  contractions,  which  increase  the  suffer- 
ing ;  slight  relief  is  afforded  by  elevating  the  limb.  Associated  with 
the  local  symptoms  are,  chiH,  fever,  quickened  pulse,  thirst,  coated 
tongue,  constipation,  and  scanty,  acid,  high-colored  urine,  which  de- 
posits, on  cooling,  a  heavy  brick-dust  sediment. 

Toward  daylight  the  symptoms  ameliorate,  to  return  again  at  sun- 
down, the  severity  gradually  lessening,  until  the  fourth  or  fifth  day, 
when  convalescence  is  established,  the  patient,  as  a  rule,  feeling  better 
than  before  the  attack. 

Chronic  Gout.  Either  the  result  of  acute  attacks  or  with  a  greater 
number  of  joints  being  attacked. 

The  paroxysms  occur  at  any  time,  but  develop  slowly,  with  less 
pronounced  local  and  general  symptoms.  Deposits  are  noticed,  the 
joints  becoming  hard,  knobby,  and  often  distorted.  The  deposits  or 
chalk-stones  (urate  of  sodium)  occur  about  the  joints,  tendons  and 
bursae,  and  helix  of  the  ear. 

Diagnosis.  An  error  cannot  occur  if  the  history  of  the  case  can 
be  obtained,  to  wit :  hereditary  tendency,  age,  sex  (females  rare,  until 
menopause),  mode  of  living,  character  of  symptoms,  and  presence  of 
the  characteristic  deposits. 

Prognosis.  Acute  gout  rarely  fatal ;  is  prone  to  return,  but  much 
depending  upon  the  mode  of  living. 

Chronic  gout  decidedly  shortens  life.  The  most  serious  signs  are 
those  indicating  advanced  renal  disease,  with  non-elimination  of  uric 
acid.  Gout  influences  unfavorably  the  prognosis  from  acute  diseases 
or  injuries. 

Treatment.  For  the  acute  paroxysms  at  once,  viiium  colchici 
radicis,  gtt.  xv-xx-  xxx,  every  two  hours,  well  diluted,  either  alone  or 
in  combination  with  a  potassa  salt,  or  sodii  salicylas,  gr.  xx,  every 
three  or  four  hours,  well  diluted,  or  Prof.  Bartholow's  pill — 

U  .     Colchicinse g*"-  7V 

Ext.  colocynth.  comp., gr.  ss. 

Quininio  sulph., gr.  iij. 

Every  two  or  three  hours. 


ACUTE  GENERAL    DISEASES.  161 

Or  the  following,  recommended  by  Loomis  : — 

K  •     Pulv.  ipecac, gr.  j 

Ext.  colchici  acet.,      gr.  j 

Hydrargyri  chlor.  mite, gr.  j 

Ext.  aloes  aq., gr.  j 

Ext.  nucis  vomicae, S^-  X-  ■^■ 

Ft.  pil.  No.  I. 

SiG. — Every  three  hours. 

For  the  J>a in,  hypodermic  injection  of  inorphina,  and  wrapping  the 
inflamed  joint  in  cotton  wool  saturated  with  liq. plumb,  sub-acetat.  dil. 
and  tmctura  opii. 

The  diet  must  be  restricted  to  liquid  food. 

For  chronic  gout,  regulated  diet,  free  action  on  the  secretions,  and 
lithii  citras  effervescentes,  5j,  three  or  four  times  a  day,  well  diluted 
with  water ;  and  perhaps  a  course  of  guinma,  ferrtivi  and  arseiii- 
cuni. 

To  prevent  paroxysm,  keep  secretions  acting,  by  the  free  use  of 
pure  water  or  a  good  alkaline  water,  especially  the  Saratoga  Vichy. 

The  diet  is  of  the  greatest  importance,  and  should  consist  chiefly 
of  vegetables  and  fruit,  excepting  tomatoes  and  strawberries  ;  fresh 
meat  may  be  used  once  a  day,  as  may  oysters,  fish  and  soups.  Alco- 
holic and  malt  liquors  are  contraindicated,  as  are  tea  and  coffee ; 
skimmed  milk  should  replace  all  the  above.  No  eggs  or  dishes 
containing  eggs,  no  pastry,  hot  bread  or  cakes,  no  sweetmeats,  spices 
or  condiments. 

Systematic  exercise,  especially  walking,  is  of  great  advantage. 

Cold  bathing,  with  caution,  while  the  vapor  or  Turkish  bath  are  of 
benefit. 

Changing  from  a  cold  to  a  warm  climate  in  winter,  and  the  use  of 
flannel  under-clothing,  are  strongly  recommended. 


LITH^MIA. 

S37Tionyras.     Lithiasis  ;  uric  acid  diathesis  ;  half  gout. 

Definition.  A  condition  in  which  the  fluids  of  the  body  are  satu- 
rated with  nitrogenized  waste,  in  the  form  of  lithic  or  ui'ic  acid ;  char- 
acterized by  marked  dyspepsia,  various  nervous  phenomena,  muscular 
and  articular  pains,  bronchial  catarrh,  all  or  any  of  these  associated 
with  scanty,  high-colored,  acid  urine. 


162  PRACTICE   OF   MEDICINE. 

Causes.  High  living,  with  little  exercise  ;  imperfect  digestion  of 
nitrogenized  food  ;  impaired  elimination  of  uric  acid. 

Symptoms.  Those  of  dyspepsia  associated  with  irregular  bowels, 
scanty,  high-colored,  acid  urine,  sp.  gr.  1.024-1.028,  containing  neither 
sugar  nor  albumin,  but  showing  an  increased  proportion  of  urates. 
Also,  depressed  spirits,  impaired  inemory,  loss  of  interest  in  occupa- 
tion, sleepless  Jiigkts,  attacks  of  vertigo,  neuralgic  ^^z/«?  in  the  head, 
and  a  constant  dread  of  apoplexy  or  cerebral  disease.  Also,  pains  in 
the  joints,  neuralgic  in  character. 

If  the  condition  be  allowed  to  continue,  the  following  organic 
changes  may  result,  to  wit :  fatty  heart ;  fibroid  kidney  ;  enlarged 
liver,  or  changes  in  the  cerebral  vessels. 

DiagTiosis.  From  gout,  by  the  absence  of  acute  paroxysms  and 
resulting  changes  in  the  joints. 

Prognosis.  If  properly  recognized  and  treated,  complete  recovery 
will  result,  although  it  is  a  disorder  of  long  duration. 

If  not  properly  treated,  develops  some  one  of  the  organic  diseases 
mentioned. 

Treatment.  Regulate  diet,  using  fresh  meat  once  daily,  poultry, 
game  (plainly  cooked),  fresh  fish,  oysters,  occasionally  eggs,  lettuce, 
spinach,  celery,  cold  slaw  and  tomatoes  ;  avoid  all  stimulants,  tea  and 
coffee,  using  milk,  skimmed  milk  or  milk  and  cream.  Act  freely  on 
all  the  secretions.  Systematic  exercise.  Avoid  tonics,  bromides, 
chloral  and  opium.  Long  course  of  alkaline  waters.  Good  results 
follow  lithii  citras,  gr.  xx,  t.  d.,  sodii  phosph.,  gr.  xxx,  ter  die,  or 
acidum  be7izoicuni,  gr.  x,  t.  d.,  all  well  diluted  with  water.  The  author 
strongly  urges  the  use  of  acidu7n  nitricum  dilutum,  gtt.  x,  in  half  a 
glass  of  water,  four  times  a  day,  with  the  occasional  use  oi  pilules  rhei 
compositce  at  bedtime. 


DIABETES  MELLITUS. 

Synonyms.     Glycosuria ;  melituria. 

Definition.  A  chronic  affection  characterized  by  the  constant 
presence  of  grape  sugar  in  the  urine,  an  excessive  urinary  discharge, 
and  the  progressive  loss  of  flesh  and  strength. 

Causes.  Most  common  in  males.  Occurs  at  all  ages,  but  most 
frequently  between  twenty-five  and  fifty  years.     It  is  often  hereditary. 


ACUTE  GENERAL   DISEASES.  163 

Disorders  of  the  nervous,  hepatic  and  renal  systems.     Excessive  use 
of  farinaceous  food  and  malt  liquors.     Sexual  excesses. 

The  ex2LCt pathology  of  diabetes  mellitus  differs  in  different  cases, 
and  in  the  present  state  of  our  knowledge  no  exclusive  view  can  be 
adopted.  Still,  there  are  reasons  for  believing  that,  in  a  large  pro- 
portion of  cases,  the  nervous  system  is  primarily  at  fault,  though  the 
character  of  the  lesions  may  differ. 

Pathological  Anatomy.  None  peculiar  to  diabetes  are  yet 
recognized. 

Hyperaemia  and  hypertrophy  of  the  liver  and  kidneys  are  gener- 
ally present,  the  result  of  increased  functional  activity. 

The  changes  in  the  lungs  peculiar  to  phthisis  are  often  found  in 
very  chronic  cases. 

The  changes  in  the  nervous  system  are  not  fully  determined. 

Symptoms.  Clinically,  cases  differ  greatly  in  their  course  and 
severity ;  one  class  presenting  slight  symptoms  and  a  chronic  course  ; 
another  class  having  marked  local  and  constitutional  symptoms  and 
an  acute  course.  The  symptoms  of  a  typical  case  may  be  arranged 
under  the  following  heads  : — 

Urinary  Organs  and  Urine.  Micturition  more  frequent  and  the 
urine  increased  in  quantity.  Paiji  over  the  region  of  the  kidneys. 
The  quantity  of  urine  may  amount  to  4,  8,  12,  20  or  30  pints  in 
twenty-four  hours.  It  is  usually  pale,  clear  and  watery,  having  a 
sweetish  taste  and  odor,  the  specific  gravity  ranging  from  1.025  ^^ 
1.050.  It  ferments  rapidly  if  kept  in  a  warm  place.  It  yields  grape 
sugar  to  the  usual  tests,  the  amount  present  varying  from  an  ounce  to 
two  pounds  in  twenty -four  hours. 

The  urea  and  uric  acid  are  increased.     Albumin  may  be  present. 

The  increased  passage  of  a  large  quantity  of  saccharine  urine  causes 
a  constant  itching,  burning  and  uneasy  sensation  at  the  prepuce, 
along  the  urethra,  and  at  the  neck  of  the  bladder ;  in  females,  itching 
and  eczema  of  the  vulva  are  common  ;  in  children,  incontinence  of 
urine  is  frequent. 

Digestive  Organs.  An  almost  constant  symptom  is  thirst,  with  a 
dry  and  parched  condition  of  the  mouth.  At  times  the  appetite  is 
excessive,  again  absent.  The  breath  may  have  a  sweetish  odor,  the 
tongue  irritable,  red  and  often  cracked.  Dyspeptic  symptoms  are 
common,  and  occasionally  vomiting.  The  bowels  are  constipated, 
the  stools  pale  and  dry.     At  times  diarrhoea  may  occur. 


164  PRACTICE   OF   MEDICINE. 

■The  patient  complains  of  feeling  very  weak,  languid,  and  of  sore- 
ness and  pain  in  the  litnbs,  there  is  more  or  less  eniaciatioti,  a  harsh, 
dry  skin,  the  countenance  distressed  and  worn. 

The  mind  is  often  greatly  altered;  depression  of  spirits,  decline  in 
firmness  of  character  and  moral  tone,  with  irritability,  are  present. 
Sexual  inclination  and  power  are  diminished.  Defects  of  vision  are 
present. 

The  blood  and  various  secretions  contain  sugar. 

Complications.  Pulmonary  phthisis ;  Bright's  disease;  defects 
of  vision  from  atrophy  of  the  retina  or  the  formation  of  a  soft  cataract ; 
boils  and  carbuncles,  and  chronic  skin  affections,  such  as  psoriasis 
and  eczema. 

Course.  The  clinical  history  varies  in  different  cases.  In  the 
majority  of  instances  the  course  is  chronic,  lasting  for  years,  the 
symptoms  beginning  insidiously,  and  becoming  progressively  worse, 
with,  at  times,  decided  remissions.  Occasionally  the  disease  runs  an 
acute  course,  death  occurring  within  four  or  five  weeks. 

Termination.  The  majority  of  cases  ultimately  prove  fatal,  the 
symptoms  markedly  changing,  the  urine  and  sugar  dimiftishing  in 
quantity,  the  occurrence  of  a/bumi7tu?'ia,  disgust  for  food  and  drink, 
and  the  development  of  hectic  fever  or  colliquative  diarrhoea. 

The  fatal  result  usually  arises  from  gradual  exhaustio?i,  from  blood 
poisoning,  leading  to  stupor,  ending  i?i  complete  coma,  or  occasionally 
to  delirium  or  co7ivulsions,  or  from  complications. 

Rarely  death  occurs  suddenly,  from  urcemic  cotivulsions  or  urceinic 
coma. 

Diagnosis.  Diabetes  mellitus  only  exists  when  grape  sugar  is 
permanently  present  in  the  urine.  "  It  is  not  the  quantity,  but  the 
persistence  of  sugar  which  constitutes  diabetes." 

When  grape  sugar  is  present  in  the  urine,  with  more  or  less  in- 
crease in  the  urinary  flow,  it  can  be  mistaken  for  no  other  affection. 

From  Bright' s  diseases,  by  the  absence  of  dropsy,  and  of  tube-casts 
in  the  urine ;  the  amount  of  albumin  in  the  urine  is  never  so  great  or 
constant  in  diabetes  mellitus  as  in  Bright's  diseases. 

From  Diabetes  insipidus,  by  the  absence  of  sugar  in  the  blood  and 
urine,  and  the  larger  quantity  of  urine  voided  in  polyuria. 

Si?nple  glycosuria  differs  from  diabetic  glycosuria  in  that  the  amount 
of  sugar  in  the  urine  is  not  constant — at  one  time  being  present,  at 
another  absent — the  amount  of  urine  voided  is  never  in  excess  of 


ACUTE   GENERAL   DISEASES.  165 

health  ;  simple  glycosuria  is  a  disease  of  the  aged  ;  diabetic  glycosuria 
usually  appears  under  fifty  years.  Simple  glycosuria  often  results 
from  the  inhalation  of  chloroform,  the  use  of  chloral,  in  the  insane, 
from  excitement,  or  the  result  of  injuries  to  the  head. 

Prognosis.  Most  unfavorable  as  regards  a  cure,  it  being  fairly 
questionable  if  complete  recovery  has  ever  occurred  in  a  typical  case. 
Still,  decided  amelioration  may  take  place  in  the  symptoms,  and  the 
progress  of  the  malady  be  greatly  retarded.  The  younger  the  patient, 
the  more  rapid  the  fatal  termination. 

Treatment.  Impress  upon  patients  the  importance  of  a  strictly 
regulated  diet.  Prohibit  or  restrict  the  consumption  of  such  articles 
as  contain  sugar  or  starch,  especially  ordinary  bread  or  flour,  sugar, 
honey,  potatoes,  peas  beans,  rice,  arrowroot,  cracked  wheat,  oat  meal, 
turnips,  beets,  corn  and  carrots  ;  prunes,  grapes,  figs,  bananas,  pears, 
apples,  and  liquors  of  all  kinds  whether  distilled  or  fermented. 

The  main  diet  should  be  of  animal  food,  including  meat,  poultry, 
game  and  fish. 

A  moderate  amount  of  fluids  should  be  allowed,  and  in  a  majority 
of  cases  jnilk  will  prove  beneficial,  although,  theoretically,  contra- 
indicated.  Tea,  coffee  and  cocoa,  without  sugar,  may  be  allowed  in 
moderation,  glycerin  or  saccharin  being  used  as  a  substitute  for  the 
sugar. 

Regulated  exercise  is  of  importance.  The  patient  should  wear 
flannel,  and  have  two  or  three  warm  baths  every  week,  or  an  occa- 
sional Turkish  bath. 

Therapeutical  Treatinent.  It  is  difificult  to  estimate  justly  the  action 
of  any  drug  in  this  disease,  for,  as  is  so  well  known,  a  proper  modi- 
fication of  the  diet  will  alone  produce  the  most  marked  improvement. 

Opium  exercises  an  influence  over  the  excretion  of  sugar,  but  the 
effect  is  not  maintained  in  all  cases.  Pavy  strongly  urges  the  use  of 
codeia  in  doses  of  gr.  ^  to  iij,  three  times  a  day.  The  use  oi  morphina 
hydrochloras,  gr.  j  daily,  ox  pulvis  opii,  gr,  iij-v  daily,  or  codcina,  gr. 
v-x-xv  daily,  I  have  seen  of  some  value.  Prof.  DaCosta  suggests  the 
use  of  ergota,  which  has  decreased  the  urinary  discharge  and  the 
quantity  of  sugar  in  a  number  of  cases.  Prof.  Bartholow  has  met 
with  an  apparent  cure  by  aDimonii  carbonas.  The  author  has  met 
with  decided  partial  success  with  uranii  nitras,  gr.  j-iij,  three  times  a 
day,  the  cases  not  yet  being  under  observation  a  sufficient  length  of 
time  to  pronounce  them  cured,  although   in  two  the  urine  has  been 


166  PRACTICE   OF   MEDICINE. 

diminished  from  three  quarts  per  day  to  normal,  the  quantity  of  sugar 
from  nine  ounces  to  less  than  half  an  ounce,  in  the  twenty-four  hours. 
Liquor  bromuium  arsenitis,  n^  iij-v,  three  times  a  day,  often  gives  good 
results.  Dickinson  remarks  that  ''  strychniiia  is,  of  all  remedies,  the 
most  constantly  useful." 

Potassii  bromidinn,  5j  during  the  twenty-four  hours,  is  strongly 
urged.  The  following  remedies  are  recommended  by  different  ob- 
servers, to  wit  :  pepsijium,  liquor  potassii  arse?iitis,  iodum,  potassii 
iodidum,  sodium  salicylas,  acidum  lacticum,  glyceri7ium,  quinina  and 
tinctura  cannabis  indica.  The  evidence  in  favor  of  the  majority  of 
these  drugs  is  far  from  satisfactory. 

Symptomatic  treatment  is  mostly  called  for.  For  emaciation  and 
anaemia, y^'rr//;;/  and  oleum  inorrhucE  ;  for  sleeplessness  and  restless- 
ness, viorphina,  potassii  bro7?iidu7?i,  chloral^  or  hyoscyamia.  For  boils 
and  carbuncles,  calcii  sulphide.  Duchenne  suggests  the  following 
solution  for  the  excessive  thirst  of  diabetic  patients  : — 

R  .     Potassii  phosphat., two  parts. 

Aquae, seventy-five  parts. 

SiG. — One  teaspoonful  twice  or  thrice  daily,  in  wine  or  hot  tea. 

The  dyspepsia  and  lung  symptoms  must  be  managed  on  general 
principles. 

The  coTis\.2^\\.  galvanic  current  )\2iS  been  productive  of  good  results. 

A  change  of  scene  and  air  is  beneficial. 

Surgical  operation  should  on  no  account  be  undertaken  on  diabetic 
patients. 

DIABETES  INSIPIDUS. 

Synonyms.     Polyuria ;  polydipsia. 

Definition.  An  affection  characterized  by  the  habitual  discharge 
of  a  very  large  quantity  of  pale,  watery  urine,  free  from  albumin  and 
sugar. 

Causes.  Occasionally  hereditary,  or  diabetes  mellitus  may  have 
existed  in  the  parent;  more  common  in  children  or  young  adults; 
men  are  more  liable  than  women  ;  injuries  and  diseases  of  the  nerv- 
ous system  ;  exposure  to  cold  ;  drinking  freely  of  cold  water  ;  fatigue; 
prolonged  debility  ;  malaria  ;  syphilis. 

The  probable  immediate  cause  of  the  excessive  flow  of  urine  con- 
sists in  dilatation  of  the  renal  vessels,  the  result  of  paralysis  of  their 


ACUTE   GENERAL   DISEASES.  167 

muscular  coat,  caused  by  derangement  of  innervation,  as  the  condi- 
tion can  be  induced  experimentally  by  irritating  a  spot  in  the  fourth 
ventricle,  or  by  section  of  portions  of  the  sympathetic  nerve. 

Sjnnptoms.  The  affection  is  characterized  \iy  great  thirst,  with  an 
increased  flow  of  pale,  watery,  slightly  acid  urine,  the  amount  varying 
from  one  to  five  or  six  gallons  in  the  twenty-four  hours.  The  specific 
gravity  ranges  from  1.001-1.007.  Sugar  and  albumin  are  absent. 
Urea  and  the  other  solids  are  increased.  The  appetite  is  voracious, 
the  bowels  are  obstinately  constipated,  and  the  skin  is  dry  and  harsh. 

The  large  flow  of  urine  is  usually  preceded  by  various  nervous 
phenomena,  as  nervousness,  irritability,  iiiability  to  concentrate  the 
mi7id,  viind  imagination,  failu7'e  of  memory,  and  headache. 

Unless  the  affection  is  soon  arrested  great  loss  of  flesh  and  strength 
result. 

Diagnosis.  It  differs  from  diabetes  mellitus  by  the  absence  of 
grape  sugar  in  the  urine. 

From  paroxysmal  diuresis,  by  the  absence  of  the  increased  urine 
permanently. 

From  interstitial  nephritis,  by  the  greater  amount  of  urinary  dis- 
charge and  the  absence  of  albumin,  oedema,  etc. 

Prognosis.  Rather  unfavorable  as  to  a  radical  cure,  unless  caused 
by  syphilis.  Death  rarely  is  due  to  the  diabetes,  but  to  some  inter- 
current malady  that  the  patient  has  been  unable  to  withstand,  on 
account  of  the  weakness  produced  by  the  diabetes. 

Treatment.  If  due  to  syphilis,  potassii  iodidum  and  hydrargyrum 
are  of  real  benefit.  Prof.  DaCosta  has  had  success  with  ergota  in  the 
form  of  the  fluid  extract  or  the  aqueous  extract.  Pilocarpus  has  been 
used  with  success.  Prof.  Bartholow  recommends  ^«/7/«;z/5w  in  cases 
not  cured  by  potassii  iodidum,  placing  "one  electrode  to  the  neck 
below  the  occiput,  the  other  to  the  hypochondriac  regions  in  turn." 
Valerian  and  potassii  bromidum  have  been  used.  The  author  has 
effected  a  cure  in  three  cases,  where  other  remedies  had  failed,  by  the 
use,  internally,  of — 

R  .     Strychnince  sulph., g""-  To 

Acii.  hyciroclilc)r.  dil., rT^x 

Aquae  lauro-cerasi,      , ^ij.  M. 

Well  diluted. 

The  obstinate  constipation  is  best  overcome  by  pilulce  catharticcs 
composites,  one  at  bedtime. 


168  PRACTICE   OF   MEDICINE. 

CHOLERA. 

Synon3rms.  Epidemic  cholera ;  Asiatic  cholera ;  malignant 
cholera  ;  spasmodic  cholera. 

Definition.  An  acute,  specific,  infectious  disease,  epidemic  in  the 
majority  of,  although  endemic  in  other,  localities  ;  characterized  by 
the  transudation  of  serum  into  the  stomach  and  intestinal  canal 
and  violent  purging  of  a  peculiar,  rice-water-like  fluid,  the  persistent 
vomiting  of  a  similar  material,  severe  muscular  cramps,  and  a  condi- 
tion of  prostration,  followed  by  collapse  and  death,  or  of  a  reaction 
from  the  collapse  and  the  development  of  the  typhoid  state  {cholera 
typhoid). 

Causes.  A  specific  poison,  probably  the  "comma  bacillus"  of 
Koch.  Cholera  is  but  feebly  contagious,  in  the  usual  acceptation  of 
that  word,  but  it  is  unquestionably  infectious. 

The  evidence  seems  conclusive  that  the  cholera  stools  are  the  main 
if  not  the  only,  channel  of  infection,  and  that  the  great  cause  of  the 
propagation  of  cholera  is  the  contamination  with  the  stools  of  the 
water  used  for  drinking  purposes.  Milk  may  also  be  the  vehicle  by 
which  it  spreads.  Little,  if  any,  danger  exists  from  being  in  the  pres- 
ence of  the  affected,  although  the  emanations  from  the  cholera 
excreta  in  the  atmosphere  may  generate  the  disease  if  swallowed  or 
inhaled.  The  dead  bodies  of  cholera  subjects  apparently  possess  a 
slight  infective  property,  the  "  bacteria  of  decomposition  "  probably 
destroying  the  cholera  germs.  One  attack  does  not  afford  protection 
against  another. 

The  period  of  incubation  is  short,  under  a  week,  usually. 

Pathological  Anatomy.  This  is,  as  yet,  far  from  satisfactory. 
The  morbid  appearances  in  the  majority  of  cases  of  death  from 
cholera  may  be  thus  summarized.  The  temperature  generally  rises 
after  death,  the  body  remaining  warm  for  a  considerable  time.  Rigor 
mortis  rapidly  ensues,  the  muscular  contractions  being  often  so  power- 
ful as  to  displace  and  distort  the  limbs.  The  skin  is  mottled  and  the 
body  greatly  shrunken.  The  blood  is  darker  in  color,  thick,  viscid, 
feebly  coagulable,  and  slightly  acid.  The  arteries  are  quite  empty  of 
blood,  the  veins,  on  the  other  hand,  are  distended.  The  organs  are, 
as  a  rule,  pale  and  shrunken. 

The  stomach  and  intestinal  mucous  membrane  are  congested,  and 
present  evidence  of  extravasations  and  ecchymoses,  or  are  bleached 


ACUTE  GENERAL   DISEASES.  169 

and  pale.  The  stomach  and  intestines  usually  contain  a  quantity  of 
whey-like  material,  having  an  alkaline  reaction,  as  well  as  quantities 
of  cast-off  epithelium  and  the  peculiar  bacillus.  It  is  thought  by 
many  that  the  stripping-off  of  the  epithelium  is  a  post-mortem  phe- 
nomena. The  Peyer's,  solitary  and  Brunner's  glands  are  usually 
enlarged  and  prominent,  and  occasionally  evidences  of  ulceration 
are  apparent  in  the  solitary  glands,  and  sections  placed  under  the 
microscope  show  the  "  comma  bacillus."  The  villi  of  the  mucous 
membrane,  as  well  as  the  epithelium  of  the  small  intestines,  are 
stripped  off,  leaving  the  basement  membrane,  for  the  most  part, 
exposed.  The  liver  is  more  or  less  advanced  in  fatty  degeneration, 
presenting  a  somewhat  mottled,  yellowish  discoloration.  The  kidneys 
are  congested,  the  epithelium  of  the  tubules  granular  and  detached 
from  the  basement  membrane,  blocking  up  the  tubes.  Prof.  Bartholow 
observed,  in  all  of  his  autopsies,  "  considerable  hyperaemia  and  dila- 
tation of  the  vessels  of  the  medulla  oblongata.  The  constancy  of  this 
lesion  would  seem  to  indicate  a  relationship  between  congestion  of 
the  medulla  and  the  cramps." 

Symptoms.  In  accordance  with  the  law  of  epidemic  infectious 
diseases,  the  onset,  course  and  character  of  the  symptoms  vary  in 
different  cases  and  at  different  periods  in  the  same  epidemic. 

The  disease  may  either  set  in  suddenly  in  a  patient  previously  in 
good  health,  or  it  may  follow  an  attack  of  rather  severe  and  persistent 
diarrhoea,  with  pain,  nausea,  vomiting  and  depression.  Such  cases  are 
termed  Cholerine,  the  stools  of  which  are  infectious. 

In  a  typical  case  there  are  three  stages :  first,  diarrhoea ;  second, 
prostration  ;  third,  collapse,  or,  in  favorable  cases,  reaction. 

First  Stage,  Begins  with  chilliness,  excessive  thirst,  coated  tongue, 
unpleasant  taste  in  the  mouth,  slight  abdominal  pain,  and  three  or 
four  copious,  zvatery,  yet  fecal  stools  during  the  day,  and  a  decided 
feeling  of  weakness,  the  stools  rapidly  becoming  whey-like,  easily 
voided,  but  with  force,  and  only  shght  pain. 

Second  Stage.  The  stools  rapidly  increase  in  number,  are  voided 
with  a  rushing  force,  and  consist  of  many  quarts  of  grayish,  or 
whitish,  rice-water-like  fluid,  accompanied  with  forcible  vomiting, 
first  of  the  contents  of  the  stomach,  mixed  with  more  or  less  bilious 
matter,  afterward  of  the  peculiar  rice-water-like  material  ;  thirst  be- 
comes most  intense,  increasing  or  diminishing  with  the  variations  in 
14 


170  PRACTICE   OF   MEDICINE. 

the  number  of  the  vomiting  and  stools  ;  severe  muscular  cramps  soon 
follow,  most  severe  in  the  calves,  although  occurring  in  all  parts  of 
the  body. 

Third  Stage.  The  stools,  vomiting  and  cramps  continue.  The  ap- 
pearance of  the  patient  becomes  frightful ;  the  eyes  are  sunken  and 
surrounded  by  blackened  rings,  the  nose  pinched  and  pointed,  the 
cheeks  hollow,  and  the  lips  blue  (facies  cholerica) ;  the  surface  cold 
and  moistened  with  a  sticky  perspiration  ;  the  skin  of  the  hands  and 
fingers  have  the  sodden  appearance  of  the  "washerwoman  who  has 
washed  all  day,"  and  if  picked  up  in  folds,  the  fold  but  slowly  dis- 
appears. The  temperature  rapidly  falls,  the  pulse  becomes  small  and 
compressible,  barely  perceptible  at  the  wrist,  and  the  heart-beats  are 
scarcely  recognizable.  The  voice  is  weak,  husky  and  sepulchral 
(vox  cholerica),  the  tongue  is  like  ice,  the  breath  is  cold  and  icy,  the 
urijie  markedly  diminished  and  albuminous.  The  mind  is  not  cloudy, 
but  most  patients  are  apathetic  and  indifferent  to  their  danger.  This, 
the  algid  stage  of  cholera,  or  cholera  asphyxia,  usually  terminates  in 
death  in  from  three  to  twelve,  twenty-four  or  forty-eight  hours,  but 
reaction  may  be  established. 

Stage  of  Reaction.  The  temperature  of  the  body  rises,  the  pulse 
gradually  becomes  fuller  and  stronger,  the  countenance  becomes 
brighter,  the  stools  less  frequent  and  more  fecal,  the  vomiting  de- 
creases, the  thirst  lessens,  the  urine  increases  in  amount,  but  con- 
tinues albuminous,  the  padent  entering  a  slow  convalescence,  or 
typhoid  symptoms  develop,  the  so-called  cholera  typhoid,  which  pro- 
longs the  recovery  for  several  weeks. 

Convalescence  is  often  prolonged  and  complicated  by  the  develop- 
ment of  severe  bed  sores,  boils,  bronchitis,  pneumonia  or  parotitis. 

Sequelae.  Suppuration  of  the  parotid  gland  ;  painful  tetanic  con- 
traction of  the  flexor  muscles  of  the  limbs  ;  abscesses  or  ulcers  of 
the  limbs;  profuse  sweats;  roseola,  erythema,  urticaria,  and  rarely 
vesicular  eruptions. 

Diagnosis.  The  epidemic  character,  and  rapid  spreading,  and 
great  mortality  of  the  affection  prevent  its  being  mistaken  for  any 
other  disease,  although  isolated  cases  are  often  confounded  with 
cholerine  or  with  cholera  morbus,  the  points  of  distinction  being  few, 
unless  the  "comma  bacillus"  only  be  found  in  the  stools  of  true 
cholera. 


ACUTE   GENERAL   DISEASES.  l7l 

Prognosis.  Very  unfavorable,  the  mortality  ranging  from  twenty 
to  eighty  per  cent.  The  last  epidemic  in  this  country  was  much 
milder  than  former  ones.  The  prognosis  is  controlled  by  the  general 
condition  of  the  patient,  the  age,  habits  and  the  development  of  the 
algid  stage  ;  the  prognosis  being  more  favorable  in  those  cases  which 
develop  gradually  than  in  those  in  which  it  reaches  its  acme  at  a 
single  bound  ;  the  very  young  or  very  old,  those  addicted  to  the 
various  excesses  and  surrounded  by  unfavorable  hygienic  conditions, 
are  more  apt  to  perish  than  are  others. 

Treatment.  The  success  depends,  to  a  great  extent,  upon  its 
prompt  and  early  treatment,  for  experience  amply  attests  that  the 
arrest  of  the  disease  in  the  diarrhoeal  stage  is  comparatively  easy, 
and  that  in  the  stage  of  collapse  its  cure  by  any  means  whatever  is 
altogether  an  exceptional  occurrence  ;  therefore,  during  the  prevalence 
of  cholera  the  mildest  cases  of  diarrhoea  ought  to  receive  prompt 
treatment,  for  many  cases  have  their  beginning  as  a  mild  diarrhoea. 

It  must  not  be  overlooked  that  intelligent  nursing  and  regimen  are 
equally  as  important  as  medical  treatment. 

First  Stage.  The  remedy  of  all  others  is  opiwn  in  some  form,  to 
which  may  be  added,  with  h^ne^t,  pi umbi ac etas,  in  doses  of  gr.  iij-v, 
repeated  p.  r.  n.,  or  aciduin  sulp/mricum  dilutuin  combined  with 
tifictiira  opii  deodoraia,  and  at  the  same  time  applying  mustard  over 
the  abdomen.  Water  and  food  should  be  used  with  great  caution, 
but  ice  is  indicated  in  limited  amounts,  and  at  times  iced  dry 
champagne.     The  patient  must  be  kept  quiet,  in  bed. 

Ziemssen  says :  "  Calomel  has  the  first  place  of  all  drugs  which 
have  been  recommended  in  the  prodromal  stage.  Begin  with  two  or 
three  doses  of  gr.  vij,  followed  with  small  doses — gr.  ^ — every  two 
hours." 

Second  Stage.  The  opium  treatment  should  be  continued,  together 
with  the  free  use  of  stimulants .  For  the  distressing  vomiting,  ice, 
iced  champagne,  acidum  carbolic um  or  acidum  hydrocyanicum  may 
sometimes  give  relief. 

Locally  either  continue  the  mustard  application  to  the  abdomen  or 
the  constant  use  of  rubber  bags  filled  with  boiling  water,  or  cold  cloths. 

For  the  crainps,  hot  water  in  bottles,  hot  irons  or  bricks  applied 
over  painful  parts,  or  an  ointment  of  chloroform  or  chloral,  chloroform 
or  ether  inhalations,  or  the  use  of  the  following  hypodermic  solution, 
strongly  recommended  by  Prof.  Bartholow  :— 


172  PKACTICE   OF    MEDICINE. 

.      R  .     Chloral, .^5  iij 

Morphin^e  sulph.,      gr.  iv 

Aq.  lauro-cerasi, f^j.  M. 

SiG. — Fifteen  to  thirty  minims  each  injection. 

For  the  collapse,  heat  to  the  surface  and  the  free  use  oi  stimiila7its, 
or  spiritus  friimenti,  or  spiritus  vi?ii  gallici,  hypodermically,  also 
the  hot,  and  in  some  cases,  the  cold  bath  has  been  of  advantage; 
the  intravenous  injection  of  saline  fluids  was  unusually  successful 
during  the  1884  epidemic  in  France,  and  as  the  modus  operandi 
becomes  more  perfect,  its  success  will  be  the  more  marked. 

If  reaction  occur,  treat  indications  as  they  arise,  and  use  tonics, 
such  2l's,  ferrum ,  qitinina  and  arse7iiciwi. 

All  the  discharges  from  the  patient  should  be  thoroughly  disinfected 
as  soon  as  voided,  and  the  stools  and  vomited  material  buried. 


TRICHINOSIS. 

Synonyms.     Trichinae;  trichina  spiralis;  "  flesh-worm  disease." 

Definition.  A  typhoid  condition,  the  result  of  the  entrance  of  a 
parasite— the  Trichina  spiralis — into  the  intestinal  canal,  and  their 
subsequent  migration  into  the  muscular  structure  ;  characterized  by 
severe  gastro-intestinal  irritation,  severe  muscular  soreness,  and  a  low 
typhoid  condition. 

Cause.  The  Trichina  spiralis  are  introduced  into  the  human 
body  by  eating  infected  hog's  flesh,  either  raw  or  but  imperfectly 
cooked. 

Description.  The  parasite  is  found  in  two  forms,  to  wit  :  intes- 
tinal trichina,  which  is  sexually  mature,  and  imiscle  trichina,  which  is 
sexually  immature. 

The  intestinal  trichifta  is  a  small,  hair-like  worm,  the  male  meas- 
uring yV  of  an  inch,  and  the  female  yi  of  an  inch  in  length  ;  the  head 
is  smaller  than  the  rest  of  the  body  ;  the  tail  of  the  male  has  a  bi-lobed 
prominence,  between  the  divisions  of  which  the  anal  opening  is  placed, 
and  from  which  a  single  spiculum  can  be  protruded  ;  the  female  has 
a  blunt,  rounded  tail,  the  reproductive  outlet  being  situated  toward 
the  anterior  part  of  the  body  ;  the  ova  are  very  small,  containing 
embryos  being  produced  viviparously  at  the  rate  of  at  least  one 
hundred  each  week  after  the  entrance  of  the  female  into  the  intestinal 
canal. 


ACUTE  GENERAL   DISEASES.  173 

The  muscle  trichina  develops  its  sexual  apparatus  after  it  has  entered 
the  intestinal  canal  of  the  host. 

The  viable  embryos  discharged  from  the  female  are  in  a  state  of 
motion,  and  at  once  migrate  from  the  intestines  to  the  muscular 
structure  of  the  individual,  and  here  set  up  inflammatory  action,  they 
becoming  surrounded  by  a  capsule  or  shell  in  which  they  are  coiled. 

After  a  time,  in  the  muscle,  the  trichina  undergoes  a  further  change  ; 
lime  salts  being  deposited  in  and  about  the  capsule  and  in  the  parasite 
itself,  when  minute  specks  of  lime  are  seen  distributed  throughout  the 
muscular  structure. 

The  development  of  the  parasite  from  the  period  of  impregnation 
up  to  the  time  of  sexual  maturity  is,  under  favorable  conditions,  less 
than  three  weeks.  Within  two  days  from  the  ingestion  of  the  infected 
pork  occurs  the  maturation  of  the  muscle  larvae  ;  in  six  days  more  the 
birth  of  embryos  occurs,  and  in  about  two  weeks  the  migrating  progeny 
have  arrived  at  their  habitat,  the  muscular  structure. 

Symptoms.  These  depend  upon  the  number  of  parasites  in  the 
infected  food.  According  to  Dr.  Sutton,  of  Indiana,  a  piece  of  pork 
the  size  of  a  cubic  inch  contained  eighty  thousand  trichinse.  There 
are  three  stages  described,  to  wit :  the  intestinal,  the  migration,  and 
the  encapsulation. 

Intestinal  Stage.  A  gastro-intestinal  inflammation,  with  7iausea, 
vomiting,  and  a  watery  diarrhcea,  the  severity  depending  upon  the 
number  of  the  parasites  ingested. 

Migration  Stage.  A  typhoid- like  fever,  rapid,  feeble  pulse,  profuse 
sweats,  intense  thirst,  dry  tongue  and  lips,  and  red,  swollen  face,  with 
soreness  and  tenderness  of  the  muscular  structure,  increased  by  any 
muscular  act.     As  a  rule  the  mind  is  clear  but  decidedly  apathetic. 

Encapsulatio7i  Stage.  If  the  number  of  parasites  ingested  have 
been  few,  recovery  may  occur  in  this  stage,  but  if  the  number  have 
been  large,  the  gastro-enteritis,  fever  and  muscular  phenomena  are 
severe,  the  patient  is  in  a  critical  condition,  between  twenty  and  fifty 
per  cent,  succumbing. 

Diagnosis.  Unless  the  physician  has  some  intimation  of  the 
cause,  cases  are  readily  mistaken  for  either  ordinary  ileo-colitis  or 
typhoid  fever. 

Prognosis.  Depends  upon  the  number  of  trichina  in  the  pork 
eaten.     Mortality  between  twenty  and  fifty  per  cent. 

Treatment.     The  preventive  treatment  consists  in  eating  no  pork 


17-4  PRACTICE   OF   MEDICINE. 

that  has  not  been  so  prepared  as  to  kill  any  trichinae  that  might  exist. 
If  the  parasites  have  been  recently  taken,  within  the  first  four  or  five 
davs,  emetics  and  purgatives  to  remove  them  from  the  stomach  and 
intestinal  canal  are  indicated.  After  thorough  action  from  these, 
attempts  may  be  made  to  destroy  such  of  the  parasites  as  have  escaped 
the  action  of  the  emetic  or  purgative.  For  this  purpose  much  is  said 
in  favor  of  g/ycerini,  one  part,  agucB,  two  parts ;  or  a  trial  can  be 
made  of  acidum  carboliciim  and  tifict.  iodi,  as  suggested  by  Prof. 
Bartholovv.  Quinina  gave  the  best  results  in  the  cases  seen  by  Dr. 
Sutton. 

After  migratio7i  has  begun,  the  powers  of  life  should  be  sustained 
by  nourishing  food,  stimulants  and  tonics. 


DISEASES    OF   THE    RESPIRATORY 

SYSTEM. 


PHYSICAL  DIAGNOSIS. 

Physical  Diagnosis  is  the  art  of  discriminating  disease  by 
means  of  the  eye,  the  ear  and  the  touch. 

The  signs  thus  ascertained  are  connected  with  changes  or  altera- 
tions in  the  form,  density,  or  condidon  of  the  structures  within,  and 
are  known  2lS  physical  signs. 

"  Physical  signs  are,  then,  the  exponents  of  physical  conditions,  and 
of  nothing  more.'' 

The  methods  employed  in  the  physical  exploration  of  the  chest, 
are:— I,  Inspection;  II,  Palpation;  III,  Mensuration;  IV, 
Percussion;  V,  Auscultation;  VI,  Succussion. 

Percussion  and  auscultation,  dealing  with  sounds,  are  of  the  greatest 
value  clinically. 

For  the  purposes  of  physical  exploration,  the  chest  is  mapped  off 
into  regions  or  divisions,  as  follows  : — 

ANTERIORLY. 

First : — Supra-clavicular,  Lying  above  the  upper  edge  of  the 
clavicle,  usually  about  an  inch  in  extent. 


DISEASES   OF  THE    RESPIRATORY  SYSTEM.  175 

Second: — Clavicular,  Corresponding  to  the  inner  two-thirds  of  the 
clavicle. 

Third  : — Infra-clavicular,  From  the  clavicle  to  the  lower  border  of 
the  third  rib. 

Fourth : — Mammary,  Between  the  third  and  sixth  ribs. 

Fifth: — Itifra-mammary ,  Downward  from  the  sixth  rib. 

LATERALLY. 

First: — Axillary,  That  portion  above  the  sixth  rib. 
Second  : — Infra- axillary,  That  portion  below  the  sixth  rib. 

POSTERIORLY. 

First : — Supra- scapular.  That  portion  above  the  scapula. 
Second  : — Scapular,  That  portion  covered  by  the  scapula. 
Third  : — Inter-scapular,  That  portion  between  the  scapulae. 
Fourth : — Infra-scapular,    That    portion  below   the  angle  of    the 
scapula. 

INSPECTION. 

Inspection  signifies  "the  act  of  looking."  Views  of  the  chest 
should  betaken  from  the  sides  and  behind  as  well  as  from  the  front ; 
for  which  purpose  a  good  light  should  be  obtained,  and  the  patient 
be  placed  in  as  easy  and  comfortable  a  position  as  is  possible. 

Inspection  reveals  \}i\^form,  size,  color,  and  movements  oi  the  chest, 
as  well  as  the  condition  of  the  superficial  parts. 

In  health  the  sides  of  the  chest  are  for  the  most  part  symmeiricalxvi 
form,  size,  color  and  movements,  both  sides  rising  equally  during  the 
act  of  inspiration,  and  falling  equally  during  the  act  of  expiration. 
During  the  act  of  inspiration  the  intercostal  spaces  in  the  lower  two- 
thirds  of  the  chest  become  more  hollow,  as  also  do  the  supra-clavicular 
fossae. 

Inspiratio7i  is  almost  entirely  the  result  of  muscular  action  ;  expira- 
tion, on  the  other  hand,  is  chiefly  due  to  the  elasticity  of  the  lungs 
and  chest  walls,  aided  somewhat  in  forced  respiration  by  muscular 
action.  The  movement  of  inspiration  by  inspection  is  of  longer 
duration  than  that  of  expiration,  and  the  pause  between  the  acts  but 
momentary. 

The  respiratory  movement'x's,  visible  over  the  whole  thorax,  although 
in  males  and  in  children  it  is  most  distinct  at  the  lower  portion 
{inferior  costal  breathing) ,  while  in  the  female  it  is  most  distinct  at 
the  upper  portion  of  the  chest  {superior  costal  breathing). 


176  PRACTICE   OF   MEDICINE. 

PALPATION. 

By  palpation  is  meant  the  application  of  the  palmar  surfaces  of 
the  hands  and  fingers  to  the  chest,  by  which  means  we  appreciate 
impressions  which  are  capable  of  being  conveyed  by  the  sense  of 
touch. 

The  objects  of  palpation  are  : — 

First : — To  give  more  accurate  information  regarding  what  is 
revealed  by  inspection. 

Second  : — To  locate  spots  of  soreness,  the  density  and  condition  of 
tumors,  if  any  be  present,  the  state  of  the  chest  walls,  the  frequency 
of  the  breathing,  and  the  action  of  the  heart. 

Third : — To  determine  the  existence  and  character  of  the  various 
kinds  oi  fremitus  (vibrations). 

By  fremitus  is  understood  certain  tactile  impressions  or  vibrations 
conveyed  to  the  surface  of  the  chest,  which  are  classed  and  produced 
as  follows : — 

First : —  Vocal  fremitus,  produced  by  the  act  of  speaking  or  crying. 

Second : —  Tussive  fremitus,  produced  by  the  act  of  coughing  ;  of 
value  especially  when  the  voice  is  very  weak. 

Third : — Broiichial  fremitus,  produced  by  the  passage  of  air 
through  mucus,  blood  or  pus,  in  the  bronchial  tubes,  during  the  act  of 
respiration. 

Fourth  : — Friction  fremitus,  produced  by  the  rubbing  together  of 
the  roughened  surfaces  of  the  pleurae. 

When  the  normal  chest  vibrates  lightly,  it  is  termed  the  normal 
vocal  fremitus. 

The  vocal  fremitus  is  more  distinct  upon  the  right  side  toward  the 
apex. 

If  the  lung  be  consolidated  (denser),  the  vibration  is  greater  and 
more  easily  distinguished — the  vocal  fremitus  is  increased. 

In  feeble  persons,  or  when  any  cause  interferes  with  the  transmission 
of  the  vibrations,  the  vocal  fremitus  is  diminished  or  absent. 


MENSURATION. 

Mensuration,  or  measurement  of  the  chest,  is  of  little  practical 
importance,  and  hence  seldom  performed.  The  only  measurement 
likely  to  be  required  is  the  circular  or  circwnferential,  in  different 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  177 

parts  of  the  chest,  which  is  performed  with  either  an  ordinary  gradu- 
ated tape  measure  or  a  double  tape  measure,  made  by  uniting  two 
tapes  in  such  a  manner  that  they  start  in  opposite  directions  from  the 
same  point  at  the  mid-spinal  line.  The  tapes  drawn  around  each 
side  until  they  meet  at  the  mid-sternal  line,  on  a  line  immediately 
above  the  nipple,  or  on  the  level  of  the  sixth  rib  near  its  attachment 
to  the  cartilage — the  sixth  costo-sternal  joint — the  patient  first  being 
directed  to  effect  a  complete  expiration,  the  number  of  inches  noted 
and  then  to  take  a  deep  inspiration,  the  increase  in  inches  noted,  the 
difference  between  the  two  giving  a  rough  estimate  of  the  capacity  ot 
the  lungs. 

In  right-handed  persons  the  right  side  is  usually  one-half  to  three- 
fourths  of  an  inch  larger  than  the  left ;  if  larger  than  this  it  is  usually 
the  result  of  some  abnormal  condition. 

In  well-developed  men  the  chest  measures  at  the  upper  part  about 
thirty-three  to  thirty-five  inches  during  expiration,  and  is  increased 
fully  three  inches  upon  inspiration. 


PERCUSSION. 

Percussion,  or  "  The  act  of  striking,"  to  ascertain  the  composi- 
tion of  structures,  affords  signs  and  information  of  great  value  in 
diagnosis. 

There  are  two  methods  employed,  immediate  and  mediate. 

Immediate,  or  direct  percussion,  is  performed  by  striking  the  thorax 
directly  with  the  points  of  the  fingers  or  the  palmar  surface  of  the 
hand.  This  method  of  percussion  has  been  generally  abandoned,  as 
it  does  not  enable  the  physician  to  distinguish,  with  sufficient  correct- 
ness, between  the  various  shades  of  difference  in  the  pitch  or  cjuality 
of  percussion  sounds. 

Mediate,  or  indirect  percussion,  may  be  practiced  in  three  different 
ways,  to  wit : — 

First : — With  the  finger  of  one  hand  interposed  between  the  body 
percussed  and  the  percussing  finger. 

Second : — With  the  finger  acting  as  a  pleximeter  and  the  percussion 
hammer. 

Third: — With  the  percussion  hammer  and  the  pleximeter. 

The  first  of  these  modes  affords  the  most  correct  and  ready  infor- 
mation regarding  the  resistance  of  the  parts  percussed.     The  skillful 

15 


178  PRACTICE    OF    MEDICINE. 

use  of  the  fingers  is  more  difficult  to  acquire  than  that  of  the  plexi- 
meter  and  hammer ;  but  if  the  examiner  has  acquired  sufficient  skill 
in  its  performance,  an  absolutely  accurate  result  may  be  obtained. 
"  He  who  is  skilled  in  digital  percussion  will  be  able  to  percuss  equally 
well  with  the  hammer,  the  inverse  of  which  does  not  always  hold 
good."  In  addition  to  being  proficient  in  the  technical  modus  ope- 
rcDidi,  it  is  necessary  to  possess  a  sensitive  ear,  educated  to  distinguish 
between  the  various  shades  of  the  sounds. 

When  the  fingers  are  employed,  it  is  a  matter  of  choice  whether  one 
or  more  fingers  are  used  as  the  pleximeter.  Usually  the  last  phalanx 
of  the  first  or  second  fingers  of  the  left  hand  is  used,  the  other  fingers 
being  raised  from  the  chest,  so  as  not  to  mttrfere  with  the  sound 
vibrations ;  they  should  be  applied  firmly  and  evet^Iy  to  the  surface, 
thus  preventing  the  slipping  of  the  soft  parts,  and  also  to  determine 
the  resistance  of  the  chest  walls  when  the  blow  is  given.  The  rounded 
efids  of  the  first  and  second  fingers  of  the  right  hand  are  used  as  a 
hammer,  striking  the  pleximeter  fingers  in  such  a  manner  that  the 
nails  shall  not  touch  the  skin  of  the  underlying  fingers.  The  force 
employed  varies  in  different  regions,  but  usually,  for  the  chest,  should 
be  only  of  moderate  degree.  Forcible  percussion  is  of  use  only  when 
the  sound  of  deep-seated  organs  is  desired. 

The  stroke  should  be  made  perpendicularly  to  the  surface  and  not 
slanting,  as  is  too  often  done.  The  whole  movement  should  proceed 
only  from  the  wrist-Joint,  and  ought  not  to  be  too  rapid  or  unequal, 
or  of  great  force,  the  fingers  being  rapidly  withdrawn,  so  as  not  to 
interfere  with  the  vibrations. 

The  objects  of  percussion  are  to  elicit  certain  sounds,  and  the 
amount  of  resistance  or  elasticity  of  the  organs  percussed. 

The  main  sounds  elicited  by  percussion  are  the  dull,  clear  and 
tympanitic.  Familiarity  with  the  iiitensity,  character  and  pitch  of 
each  of  these  sounds  is  essential 

When  percussing  the  healthy  chest,  the  sound  obtained  is  termed 
the  normal  pulmonary  resonance.  It  is  of  variable  intensity,  depend- 
ing upon  the  force  of  the  stroke  employed  and  the  amount  of  adipose 
and  muscular  tissues  covering  the  thorax,  and  the  tension  of  the  chest 
walls. 

There  is  no  exact  standard  of  the  normal  pulmonary  or  vesicular 
resonance,  but  if  the  two  sides  of  the  chest  are  compared,  the  normal 
standard  of  each  person  is  obtained. 


DISEASES   OF   THE   RESPIRATORY   SYSTEM.  179 

The  character  is  termed  pti/monary  or  clear,  as  characteristic  of  the 
healthy  chest  wall.     The  pitch  is  always  relatively  low. 

The  sounds  elicited  by  percussing  a  healthy  chest  are  not,  however, 
alike  over  all  its  parts. 

Anteriorly,  the  portion  of  lung  above  the  clavicle  yields  a  sound 
which  becomes  somewhat  tyjnpanitic  as  the  trachea  is  approached. 

Over  the  clavicle  the  sound  is  clear  and  pulmonary  at  the  centre  of 
the  bone,  but  at  the  scapular  extremity  it  is  duller,  and  towards  the 
sternum  it  becomes  somewhat  tympanitic. 

At  the  infra-clavicular  region  the  resonance  is  clear  and  distinct, 
but  little  resistance  being  offered  to  the  percussing  finger,  and  the 
sound  elicited  may  be  taken  as  the  type  of  the  pulmonary  resonance. 
In  this  region,  however,  a  slight  disparity  exists  between  the  two 
sides  ;  on  the  right  side  the  sound  is  less  clear,  shorter  and  of  a  higher 
pitch  than  on  the  left  side. 

In  the  mammary  region  of  the  right  side  the  resonance  of  the  lung 
is  not  so  clear,  the  sound  being  modified  by  the  size  of  the  mamma 
and  the  upper  border  of  the  liver.  On  the  left  side  the  heart  deadens 
the  sound  from  the  fourth  to  the  sixth  rib,  and  in  a  transverse 
direction,  from  the  sternum  to  the  left  nipple.  This  dull  sound 
in  the  left  mammary  region  is  lessened  in  extent  during  full  inspi- 
ration, and  in  emphysema,  when  the  lung  more  completely  covers 
the  heart. 

In  the  infra-mamjnary  region  on  the  right  side  the  percussion  note 
is  dull,  except  during  the  act  of  complete  inspiration,  when  the  liver 
is  displaced  downward  by  the  inflated  lung.  In  the  left  infra-mam- 
mary region  the  sound  consists  of  a  mixture  of  the  dull  sound  of  the 
heart  and  spleen  and  of  the  clear  sound  of  the  lung,  together  with 
the  tympanitic  sound  of  the  stomach. 

Over  the,  upper  part  of  the  sternum — above  the  third  rib — the  sound 
is  slightly  tympanitic.  Below  the  third  rib,  over  the  sternum,  the 
sound  is  dull,  due  to  the  presence  of  the  heart  and  liver. 

The  position  exercises  some  influence  on  the  results  of  percussion. 
More  accurate  results  are  obtained  when  the  patient  is  standing  or 
sitting  than  when  recumbent.  While  the  front  of  the  chest  is  per- 
cussed, the  arms  should  hang  loosely  by  the  sides  ;  the  hands  may 
be  clasped  across  the  top  of  the  head  during  the  percussion  of  the 
axillary  region  ;  during  the  examination  of  the  back  the  head  must 
be  bent  forward  and  the  arms  tightly  crossed  in  front. 


180  PRACTICE   OF   MEDICINE. 

On  the  posterior  surface  of  the  chest  the  sound  also  varies  according 
to  the  part  percussed. 

Over  the  scapulcE  the  sound  is  duller  than  between  these  bones  or 
below  their  inferior  angles. 

Over  the  infra-scapular  region  a  clear  sound  is  obtained  as  far  as 
the  lower  border  of  the  tenth  rib  on  the  right  side,  where  the  dullness 
of  the  liver  begins.  On  the  left  side,  below  the  angle  of  the  scapula, 
the  percussion  sound  is  tympanitic  if  the  intestines  are  distended,  or 
it  may  be  slightly  dull  if  the  spleen  be  enlarged. 

In  the  axillary  region  the  sound  is  clear  and  distinct  on  each  side. 

In  the  infra-axillary  region  of  the  right  side  the  sound  is  dicller, 
owing  to  the  presence  of  the  liver ;  at  the  corresponding  situation  on 
the  left  side,  the  sound  is  clear  or  tympanitic,  from  the  distention 
of  the  stomach,  and  at  the  ninth  or  tenth  rib  of  the  left  axillary 
region  dullness  and  the  sense  of  resistance  mark  the  location  of  the 
spleen. 

The  sounds  obtained  by  percussion  of  the  unhealthy  or  abnormal 
chest  are  as  follows  : — 

First : — Hyper-resonance  or  an  increase  of  the  normal  pulmonary 
resonance  is  due  to  the  relative  increase  in  the  proportion  of  air  to 
the  solid  tissues  of  the  lung,  providmg  the  tension  of  the  chest  walls 
be  not  altered,  occurring  in  emphysema  of  the  lungs,  atrophy  of  the 
lungs,  or  consolidation  of  the  opposite  lung. 

Second : — Dullness  or  an  absence  of  resonance  due  to  the  relative 
increase  of  soHd  tissues  in  proportion  to  the  amount  of  air,  as  seen  in 
the  different  stages  of  phthisis,  in  pneumonia,  or  pleurisy. 

The  pitch  is  increased  or  heightejied  in  proportion  to  the  diminution 
of  the  amount  of  the  air  and  the  increase  of  the  solids. 

If  there  be  entire  want  of  resonance  the  percussion  note  is  said  to 
he  flat ;  if  there  is  a  slight  decrease  in  the  resonance  of  the  part  the 
note  is  said  to  be  impaired. 

The  sense  of  resistance  is  greater,  the  more  marked  the  consolida- 
tion of  the  lungs  and  the  greater  the  tension  of  the  chest  walls. 

Third : — Tyfnpanitic,  or  the  drum-like  percussion  note,  is  a  non- 
vesicular sound  having  the  character  elicited  by  percussing  over  the 
normal  intestines;  wherever  heard  it  indicates  the  presence  of  air  in 
conditions  similar  to  that  of  the  intestines,  to  wit :  inclosed  in  walls 
which  arc  yielding,  but  neither  tense  nor  very  thick. 

When   elicited  over    the  chest  it   may  be  due  to  the  transmitted 


DISEASES   OF  THE    RESPIRATORY   SYSTEM.  181 

sound  of  the  distended  stomach  or  colon.  It  is  obtained  over  the 
chest  in  pneumothorax,  in  moderate  pleural  effusions  above  the  level 
of  the  hquid,  over  the  seat  of  cavities  in  the  pulmonary  tissues,  and 
in  oedema  of  the  lungs. 

The  tympanitic  percussion  note  differs  from  the  normal  pulmonary 
resonance  in  being  more  ringing  in  character  and  of  a  higher 
pitch. 

The  amphoric  or  metallic  sound  is  in  reality  a  concentrated  tym- 
panitic sound  of  high  pitch,  and  denotes  a  large  cavity  with  firm, 
elastic  walls. 

The  cracked-pot  or  cracked-metal  sound  is  another  variety  of  the 
tympanitic  sound.  The  condition  most  commonly  occasioning  this 
sound  is  a  cavity  in  the  lung  tissue,  communicating  with  a  bronchial 
tube.  It  requires  for  its  development  a  strong,  quick  blow  of  the 
percussing  finger,  with  the  patient's  mouth  open. 

RESPIRATORY   PERCUSSION. 

The  percussion  sound  will  vary  greatly  with  the  respiratory  move- 
ments. If  a  full  inspiration  be  taken  and  percussion  performed,  then 
a  full  expiration  taken  and  percussion  performed,  and  then  the  chest 
percussed  during  the  normal  respiration,  slight  changes  in  the  char- 
acter and  pitch  of  the  note  are  obtained,  which  otherwise  would 
escape  detection.  Prof.  DaCosta  has  designated  this  method,  respira- 
tory percussion. 

AUSCULTATORY   PERCUSSION. 

This  method  consists  in  listening,  with  a  stethoscope  appHed  to  the 
thorax,  to  the  sounds  ehcited  by  percussion.  "  It  is  a  serviceable 
means  of  determining  with  accuracy  the  boundaries  of  various  organs, 
as  those  of  the  lungs  or  heart,  or  of  the  liver  or  spleen,  and  yields 
particularly  exact  results  when  carried  out  with  the  double  stetho- 
scope." 

AUSCULTATION. 

Auscultation,  or  listening  to  the  sounds  produced  within  the 
chest  during  the  act  of  respiration,  coughing,  or  speaking,  furnishes 
the  most  rehable  means  of  studying  the  condition  of  the  lungs,  and 
is,  therefore,  the  most  valuable  method  of  discriminating  between  the 
various  conditions  which  may  affect  the  organs  of  respiration. 

Auscultation  is  either  immediate  or  mediate. 


182  PRACTICE   OF   MEDICINE. 

It  is  immediate  when  the  ear  is  applied  directly  to  the  chest,  which 
may  be  either  denuded  or  thinly  covered. 

It  is  mediate  when  the  sounds  are  conducted  to  the  ear  by  means 
of  a  tubular  instrument,  termed  a  stethoscope. 

For  ordinary  purposes,  immediate,  or  direct  auscultation  is  suffi- 
cient, but  when  it  is  desirable  to  analyze  circumscribed  sounds,  as  in 
diseases  of  the  heart,  or  where  the  patient  objects  to  this  method,  on 
the  score  of  delicacy,  or  the  auscultator  objects,  on  account  of  the  un- 
cleanliness  of  the  person  examined,  the  stethoscope  is  to  be  preferred. 
Moreover,  there  are  certain  parts  of  the  chest  which  can  only  be  ex- 
plored satisfactorily  by  the  aid  of  a  stethoscope,  and  moreover,  this 
instrument  has  the  additional  advantage  of  i7itensifying  the  sound. 

In  auscultation,  the  following  rules,  formulated  by  Prof.  DaCosta, 
should  be  observed  : — 

"  I.  Place  yourself  and  your  patient  in  a  position  which  is  the  least 
constrained  and  permits  of  the  most  accurate  application  of  the  ear 
or  stethoscope  to  the  surface.  Above  all,  avoid  stooping,  or  having 
the  head  too  low." 

"  2.  Let  the  chest  be  bare,  or  what  is  better,  covered  only  with  a 
towel  or  a  thin  shirt." 

"  3.  If  a  stethoscope  be  employed,  apply  closely  to  the  surface,  but 
abstain  from  pressing  with  it.  This  may  be  obviated  by  steadying  the 
instrument,  immediately  above  its  expanded  extremity,  between  the 
thumb  and  the  index  finger." 

"  4.  Examine  repeatedly  the  different  portions  of  the  chest,  and 
compare  them  with  one  another  while  the  patient  is  breathing  quietly. 
Making  him  cough,  or  draw  a  full  breath,  is,  at  times,  of  service ; 
especially  the  former,  when  he  does  not  know  how  to  breathe." 

SOUNDS    IN   HEALTH. 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  per- 
son, a  sound  is  heard  with  both  the  act  of  inspiration  and  respiration. 
Its  intensity  is  variable,  its  pitch  hit^h,  and  its  quality  tubular  (to  wit : 
a  current  of  air  passing  through  a  tube — the  larynx  or  trachea).  The 
duration  of  the  sound  during  inspiration  being  somewhat  longer  than 
during  expiration.     A  short  pause  follows  the  act  of  expiration. 

This  sound  is  termed  the  nontial  laryngeal  respiration,  and  is 
identical  in  character,  duration  and  pitch  with  an  important  morbid 
sound,  termed  bronchial  respiration. 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  ]  83 

The  sound  heard  by  placing  the  ear  over  the  lung  tissue  is  differ- 
ent ;  it  is  produced  in  the  very  finest  bronchial  tubes  and  air  cells  by 
their  expansion  and  contraction,  and  is  termed  the  normal  vesiculat 
mumtur. 

The  inspiratory  portion  of  the  sound  is  of  variable  intensity,  its 
pitch  is  low,  its  quality  soft  and  breezy,  designated  vesicular ;  its 
duration  is  during  the  entire  act  of  inspiration. 

The  expiratory  portion  of  the  sound  is  not  always  perceptible  ;  it  is 
oi  feeble  intensity,  very  low  pitch,  its  character  soft  and  blowing,  and 
its  duration  much  less  than  the  act  of  expiration. 

It  is  to  be  remembered,  however,  that  the  vesicular  murmur  will  be 
found  to  vary  in  the  different  regions  on  the  same  side,  and  in  corre- 
sponding regions  on  the  two  sides  of  the  chest.  These  variations 
within  the  range  of  health  are  especially  important,  and  should  be 
memorized. 

Infra-clavicular  Region. — The  vesicular  murmur  in  this  region  on 
either  side  is  much  more  distinct  than  over  any  other  part  of  the 
chest. 

On  the  left  side  the  inspiratory  sound  is  of  greater  intensity,  of 
lower  pitch,  and  more  distinctly  vesicular  in  quality  than  that  heard 
upon  the  right  side.  On  the  right  side  the  expiratory  sound  is  nearly 
or  quite  the  same  in  length  as  the  inspiratory  sound,  and  is  higher  in 
pitch  and  more  tubular  in  quality  than  the  expiratory  sound  upon  the 
left  side. 

Supra-scapular  Region. — Owing  to  the  small  number  of  air  vesicles 
and  the  large  number  of  bronchial  tubes,  and  their  nearness  to  the 
surface,  the  respiratory  murmur  has  an  intense,  high-pitched,  tubular 
and  expiratory  quality. 

Scapular  Region. — Compared  with  the  infra-clavicular  region,  the 
respiratory  murmur  heard  over  the  scapulae  on  either  side  is  more 
feeble,  and  the  vesicular  quality  less  marked. 

Inter-scapular  Region. — The  murmur  in  this  region  differs  from  the 
normal  laryngeal  breathing  only  in  intensity  and  duration. 

Infra  scapular  Region. — The  murmur  in  this  region  very  closely 
resembles  that  heard  in  the  left  infra-clavicular  region. 

Mammary  and  Infra-mammary  Regions. — The  murmur  in  these 
regions  differs  from  that  heard  in  the  infra-clavicular  region,  in  being 
of  less  intensity. 

Axillary  and  Infra-axillary   Regiojis. — The  respiratory  sound  in 


184  PRACTICE   OF   MEDICINE. 

the " axillan,'  regions  is  as  intense  as  in  any  portion  of  the  chest.     In 
the  infra-axillary  regions  the  intensity  is  less  and  the  pitch  lower. 

VOICE    IN    HEALTH. 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  per- 
son, and  he  be  directed  to  count  "  twenty-one,  twenty-two,  twenty- 
three,"  in  a  uniform  tone  and  with  moderate  force^  there  is  perceived 
a  strong  resonance,  with  a  sensation  of  concussion  or  shock,  and  a 
sense  of  vibration,  thrill  or  fremitus,  the  voice  seeming  to  be  concen- 
trated and  near  the  ear.  Often  the  articulated  words  are  distinctly 
transmitted  (laryngophony). 

The  sounds  thus  heard  are  termed  the  normal  laryngeal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly,  on 
either  side  of  the  chest  of  a  healthy  person,  and  he  be  directed  to 
count  "  twenty-one,  twenty-two,  twenty-three,"  in  a  uniform  tone,  with 
moderate  force,  a  confused  distant  hum  is  perceived,  of  variable  in- 
tensity, accompanied  with  more  or  less  vibration,  thrill  or  fremitus, 
most  distinct  in  adults,  but  notably  weaker  in  women  than  in  men. 

This  sound  is  termed  the  normal  vocal resotiance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly,  of 
a  healthy  person,  and  he  be  directed  to  whisper,  in  a  uniform  manner, 
the  words  "  twenty-one,  twenty-two,  twenty-three,"  there  is  heard  a 
sound  corresponding  closely  in  character  to  the  sound  of  expiration 
over  the  same  region  during  the  act  of  forced  respiration  ;  or,  in  other 
words,  a  feeble,  low-pitched,  blowing  sound. 

This  sound  is  termed  the  normal  bronchial  whisper,  and  is  pro- 
duced by  the  air  in  the  bronchial  tubes  during  the  act  of  expiration. 

SOUNDS   IN   DISEASE. 

The  vesicular  murmur  may  undergo,  in  disease,  changes  in  its  in- 
tensity, its  rhythm,  and  in  its  character. 

The  intensity  of  the  respiratory  murmur  may  be  : — 

1.  Exaggerated  ox  increased. 

2.  Dimi7iished  ox  feeble. 

3.  Absent  or  suppressed. 

Exaggerated  respiration  differs  from  the  normal  vesicular 
respiration  only  in  an  increase  in  the  intensity  of  the  respiratory 
sounds.  When  general  over  one  lung,  it  will  usually  indicate  deficient 
action  of  other  parts.     In  this  manner  an  effusion  compressing  one 


DISEASES   OF  THE    RESPIRATORY   SYSTEM.  185 

lung,  one-sided  deposits,  obstruction  of  the  bronchial  tubes  by  secre- 
tion, or  inflammation  of  the  lung  structure,  necessitate  a  siipple- 
jnentary  respiration  in  a  healthy  portion  of  the  same  lung  or  the 
lung  upon  the-  opposite  side.  From  its  resemblance  to  the  loud, 
strong,  quick  respiration  of  young  children,  it  has  been  termed 
puerile  respiration. 

Exaggerated  respiration  is,  therefore,  to  be  regarded  as  indirect 
evidence  of  disease  in  some  portion  of  the  pulmonary  tissue. 

Diminished  respiration,  called  also  senile  respiration,  as  being 
characteristic  of  old  age,  is  characterized  by  diminished  intensity  and 
duration  of  the  sound.  In  the  large  majority  of  instances  the  inspi- 
ration suffers  the  greatest,  the  expiratory  sound  not  diminishing  in  the 
same  proportion.  In  asthma,  emphysema,  diseases  of  the  larynx  and 
bronchial  tubes,  pleuritic  pain,  rheumatism  cr  paralysis  of  the  chest 
walls,  or  in  thickening  of  the  pleural  membrane,  we  observe  superfi- 
cial or  diminished  respiration.  When  one  side  of  the  chest  is 
partially  filled  with  fluid,  we  may  hear  a  deep-seated,  but  feeble 
breath  sound. 

Absent  or  suppressed  respiration  occurs  whenever  the 
action  of  the  lung  is  suspended  ;  this  may  be  from  external  pressure, 
as  when  the  lung  is  compressed  by  the  pressure  of  fluid  or  air  in  the 
pleural  cavity,  or  when  complete  obstruction  of  the  bronchial  tubes 
prevents  the  air  from  either  entering  or  escaping  from  the  lungs. 

The  rhythm  of  the  respiratory  murmur  may  be — 

1 .  Bitemcpted  or  jerky. 

2.  The  interval  between  inspiration  and  expiratioii  prolonged, 

3.  Expiration  prolonged. 

In  health  the  inspiratory  and  expiratory  sounds  are  even  and  con- 
tinuous, with  a  short  interval  between  each  act ;  this  may  be  altered 
in  disease,  and  both  sounds,  especially  the  inspiratory,  have  an  inter- 
rupted or  jerky  character,  termed  "cog-wheel  respiration." 

This  jerky  breathing"  is  noted  in  some  spasmodic  affections  of 
the  air  tubes,  in  hysteria,  the  earliest  stages  of  pleurisy,  pleurodynia, 
and  the  early  stages  of  pulmonary  phthisis.  It  is  most  frequently 
associated  with  phthisis,  due  probably  to  the  adhering  to  the  walls  of 
the  finer  bronchial  tubes  of  tough  mucus,  which  obstructs  the  free 
entrance  and  exit  of  the  air ;  it  is  usually  most  notable  under  the 
clavicles. 

The  interval  between  inspiration  and  expiration  may 


186  PRACTICE   OF   MEDICINE. 

be  prolonged,  instead  of  these  two  sounds  closely  succeeding  one 
another.  When  this  occurs  the  inspiratory  sound  may  be  shortened, 
or  the  expiratory  sound  may  be  delayed  in  its  commencement.  If 
the  inspiratory  sound  is  shortened,  it  is  the  result  of  consohdation  of 
the  lungs;  iftheexpiratory  sound  is  delayed,  it  is  the  result  of  lessened 
elasticity  of  the  lung  structure,  and  is  most  commonly  associated  with 
emphysema. 

Prolonged  expiration  denotes  that  the  air  is  obstructed  in  its 
exit  from  the  lungs.  It  may  be  the  result  of  diminished  elasticity, 
the  result  of  emphysema,  or  from  the  deposit  of  tubercles,  which 
impair  the  contractile  power  of  the  lungs.  If  the  former,  it  is  asso- 
ciated with  clearness  on  percussion  ;  if  the  latter,  however,  with 
impaired  resonance  on  percussion.  When  prolonged  expiration  is 
detected  in  the  apex  of  the  lung,  and  is  associated  with  impairment 
of  the  normal  pulmonary  resonance,  it  is  for  the  most  part  the  result 
of  a  tubercular  deposit. 

The  quality  of  the  respiratory  murmur  may  be — 

1.  Harsh,  termed  vesiculo-bronchial respiration . 

2.  Broftchial. 

3.  Cavernous. 

4.  Amphoric. 

Harsh  respiration,  or,  as  it  is  termed  by  Prof,  DaCosta,  vesiculo- 
bronchial respiration,  is  that  variety  in  which  both  the  inspiratory  and 
expiratory  sounds  have  lost  their  natural  softness.  It  generally  indi- 
cates more  or  less  consolidation  of  lung  tissue.  In  normal  vesicular 
respiration  the  sounds  produced  by  the  air  expanding  the  air  cells  and 
finer  bronchial  tubes  obscure  the  sound  produced  by  the  passage  of 
air  through  the  larger  bronchial  tubes,  the  healthy  lung  being  an 
imperfect  conductor  of  sound,  so  that  as  soon  as  any  portion  of  the 
lung  becomes  consolidated  the  vesicular  element  of  the  respiratory 
sound  is  diminished,  the  bronchial  element  becoming  prominent. 
Harsh  respiratio7i  is,  then,  a  union  of  the  vesicular  and  bronchial 
sounds,  being  a  vesicular  sound  mixed  with  some  of  the  qualities  of  a 
bronchial  sound,  the  expiration  being  prolonged  and  tubular  in 
character.  It  is  present  when  the  bronchial  mucous  membrane  is 
swollen,  as  in  the  earlier  stages  of  bronchitis,  also  in  the  earlier  stages 
of  phthisis  and  pneumonia. 

Bronchial  respiration  is  characterized  by  an  entire  absence  of 
all  the  vesicular  quality,     inspiration  is  of  hii^^-h  pitch  and  tubular  in 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  187 

character;  expiration  still  higher  iti  pitch,  of  greater  intensity, /r^- 
longed  and  tubular  in  quality  ;  the  two  sounds  being  separated  by  a 
brief  interval. 

The  bronchial  respiration  encountered  in  disease  closely  resembles 
that  heard  in  health  over  the  larynx  or  trachea.  Whenever  bronchial 
respiration  is  present  where,  in  health,  the  normal  vesicular  murmur 
should  be  heard,  it  indicates  consolidation  of  the  lung  structure. 

Cavernous  respiration  is  a  variety  of  the  bronchial  respiration, 
at  least  so  far  as  the  quality  of  the  sound  is  concerned.  It  is  essen- 
tially a  blowing  sound,  yet  not  always  heard  during  both  the  act  of 
inspiration  and  expiration,  being  often  only  perceptible  in  the  one, 
and  in  the  other  mixed  with  gurgling  sounds.  Its  pitch  is  lower  than 
that  of  ordinary  bronchial  respiration,  and  its  character  is  hollow. 

For  its  production  there  must  be  a  cavity  of  considerable  size  in 
the  lung  substance,  not  filled  with  fluid,  near  the  surface  of  the  chest 
walls,  communicating  with  a  bronchial  tube.  It  is  met  with  most 
commonly  in  the  last  stages  of  pulmonary  consumption,  although 
hollow  spaces  of  any  kind,  from  abscess  or  dilatation  of  the  bronchial 
tubes,  occasion  it. 

Amphoric  respiration  is  a  blowing  respiration,  having  a 
musical  or  metallic  quality.  It  is  a  variety  of  bronchial  respiration 
produced  in  a  large  cavity  whh  firm  walls,  permitting  the  reflection 
of  the  sound.  An  imitation  of  this  sound,  although  only  an  imperfect 
one,  is  produced  by  blowing  over  the  mouth  of  an  empty  bottle. 
The  amphoric  character  is  present  with  both  the  act  of  inspiration 
and  expiration. 

Amphoric  or  metallic  respiration  is  indicative  of  a  large  cavity,  not 
common  in  phthisis,  but  much  oftener  heard  at  the  upper  part  of  a 
lung  compressed  by  fluid  and  air,  as  in  pneumo-hydrothorax. 

RALES. 

Rales,  or,  as  they  are  termed,  adventitious  sounds,  because  they 
have  no  analogue  in  the  healthy  state,  cannot  be  considered  as  modi- 
fications of  the  normal  respiration. 

Grouped  according  to  the  anatomical  situation  in  which  they  are 
produced,  we  have  : — 

1.  Laryngeal  and  tracheal  rales. 

2.  Bronchial  rales. 


188  PRACTICE   OF   MEDICINE. 

'3.    Vesicular  rales. 

4.  Cavernous  rales. 

5.  Pleural  rales. 

Rfiles  may  be  divided  into  two  groups,  according  to  their  character, 
to  wit :  dry  and  vioist,  and  may  be  audible  either  during  the  act  of 
inspiration  or  expiration,  or  during  both. 

Dry  rales,  for  the  most  part,  are  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which,  therefore, 
temporarily  lessens  the  calibre  of  the  bronchial  tubes.  When  this 
narrowing  exists  in  the  smaller  bronchial  tubes  the  resulting  sound  is 
high-pitched,  or  the  rale  is  said  to  be  sibilant  or  whistling  ;  when  the 
narrowing  exists  in  the  larger  bronchial  tubes,  the  rale  is  low-pitched, 
more  musical  in  character,  or  so?iorous. 

Dry  rales  are  particularly  prone  to  be  dislodged  by  coughing,  and 
when  they  are  uninfluenced  by  the  acts  of  breathing  or  coughing, 
they  do  not  depend  upon  the  presence  of  secretions,  but  upon  the 
narrowing  of  the  air  tubes  from  the  pressure  of  tumors,  or  from  a 
thickened  fold  of  mucous  membrane,  or  from  a  spasmodic  contrac- 
tion of  the  air  tubes. 

Moist  rfiles  are  those  produced  by  the  air  passing  through  thin 
fluids,  such  as  mucus,  blood,  serum,  or  pus,  during  the  respiratory 
movements.  When  the  fluid  exists  in  the  smaller  bronchial  tubes, 
the  rales  are  termed  small  bubbling,  mucous,  or  subcrepitant.  When 
the  fluid  exists  in  the  large  bronchial  tubes,  the  rales  are  said  to  be 
large  bubbling  or  mucous. 

Moist  rales  are  not  persistent,  but  vary  in  intensity,  and  shift  their 
positions  as  the  air  drives  the  liquid  which  occasions  them  before 
it,  or  during  violent  attacks  of  coughing,  or  after  copious  expectora- 
tion. 

Laryngeal  and  tracheal  rales  are  those  produced  within  the 
larynx  and  trachea,  and  may  be  either  moist  or  dry.  The  moist  or 
bubbling  sounds,  produced  when  mucus  or  other  liquids  accumulate 
in  this  part  of  the  air  tubes,  frequently  occur  in  the  moribund  state, 
and  are  then  known  as  the  "  death  rattles."  When  not  due  to  this 
condition,  they  denote  either  insensibility  to  the  presence  of  liquid, 
as  in  stupor  or  coma,  or  inability  to  remove  liquid  by  the  acts  of 
expectoration,  as  in  croup  or  inflammation  of  these  parts  in  the  very 
feeble. 

The  dry  rales  produced  within  the  larynx  or  trachea  are  generally 


DISEASES   OF   THE    RESPIRATORY  SYSTEM.  189 

caused  by  spasm  of  the  glottis,  to  wit:  laryngismus  stridulus, 
whooping  cough  or  croup,  or  from  the  presence  of  a  foreign  body 
in  the  part. 

Bronchial  rales,  resulting  from  the  passage  of  air  through  the 
thin  liquid,  occasion  bubbling  sounds.  When  the  liquid  is  present 
in  the  larger-sized  branchial  tubes,  the  rales  are  said  to  be  large 
bubbling,  or  large  mucous  rales,  and  are  heard  in  acute  or  chronic 
bronchitis. 

When  the  liquid  is  in  the  smaller  bronchial  tubes,  the  resulting  rale 
is  called  small  bubbling,  small  mucous,  or  subcrepitant,  also  occurring 
in  acute  or  chronic  bronchitis. 

Bronchial  rales  due  to  the  narrowing  of  the  tube  by  its  spasmodic 
contraction,  or  to  the  presence  of  tough,  tenacious  mucus,  which  is  set 
in  vibration  by  the  passage  of  the  air  through  the  bronchial  tubes,  are 
termed  dry  bronchial  rales.  Frequently  they  are  suggestive  of  cer- 
tain familiar  sounds,  such  as  snoring,  cooing,  humming,  or  wheezing, 
or  they  are  often  musical  notes.  When  produced  in  the  smaller 
bronchial  tubes,  they  are  termed  sibilant,  or  high-pitched  rales  :  when 
produced  in  the  larger  bronchial  tubes,  they  are  termed  sonorous  or 
low-pitched  rales.  They  principally  occur  in  the  dry  stage  of  bron- 
chitis, or  during  an  asthmatic  paroxysm. 

The  vesicular  rale,  or,  as  it  is  more  commonly  termed,  the 
crepitant  rale,  is  produced  within  the  air  vesicles  or  at  the  terminal 
portion  of  the  smaller  bronchial  tubes. 

It  is  to  be  distinguished  from  very  fine  bubbling  sounds,  or  the  sub- 
crepitant rale.  "  //  is  a  very  fiiie  soitnd,  or  rather  series  of  very  fi7ie 
uniform  sounds,  occurring  in  puffs  and  liinited  to  inspiration.''  It 
resembles  the  noise  occasioned  by  throwing  salt  on  the  fire,  or  alter- 
nately pressing  and  separating  the  thumb  and  finger,  moistened  with 
a  solution  of  gum  arable,  and  held  near  the  ear,  or  rubbing  together  a 
lock  of  dry  hair  near  the  ear. 

The  crepitant  rale  is  produced  by  the  movement  of  fluid  in  the 
air  cells  or  in  the  finest  extremities  of  the  bronchial  tubes,  or  by  the 
forcing  open,  during  the  act  of  inspiration,  of  the  air  cells  aggluti- 
nated by  exuded  lymph.  These  sounds  may  be  defined  as  being 
very  fine,  dry,  crackling  sounds,  heard  at  the  end  of  inspiration.  They 
are  usually  present  in  the  first  stages  of  pneumonia,  and  when  limited 
to  the  apices,  are  significant  of  the  incipient  stage  of  phthisis. 

Cavernous  rales,   or,   as  they  are  commonly  termed,  gurgling 


190  PRACTICE   OF   MEDICINE. 

rates,  are  produced  in  a  pulmonary  cavity  of  considerable  size, 
containing  a  large  amount  of  liquid  communicating  freely  with  a 
bronchial  tube.  The  sound  is  occasioned  by  the  agitation  of  the 
liquid  within  the  cavity,  and  may  be  compared  to  the  sound  produced 
by  the  boiling  of  liquid  in  a  flask  or  large  test-tube.  The  sound 
is  sometimes  high-pitched  or  musical,  whence  it  has  been  termed 
"  amphoric  gurgling,"  but  it  is  generally  low  in  pitch.  The  rale  is 
heard  almost  exclusively  during  the  act  of  inspiration,  and  its  diag- 
nostic importance  relates  to  the  advanced  stage  of  phthisis. 

Pleural  rules  may  be  either  dry  or  moist. 

Dry  pleural  rales,  or,  as  they  are  more  commonly  termed,  friction 
sounds,  are  occasioned  when  the  surfaces  of  the  pleurae  are  covered 
with  a  glutinous  substance  preventing  the  unobstructed  movements  of 
the  pleural  surfaces  upon  each  other  during  the  respiratory  acts,  for 
in  health  these  movements  occasion  no  sound  whatever.  The  sounds 
are  generally  interrupted  or  irregular,  occurring  during  the  act  of 
inspiration  or  expiration,  or  during  both  acts.  The  character  of  the 
sound  is  variable,  being  termed  rubbing,  grazing,  rasping,  grating  or 
creaking,  according  to  the  intensity  of  the  respiratory  acts  and  the 
amount  of  exudation. 

They  are  distinguished  by  the  apparent  nearness  of  the  sound  to 
the  ear,  and  are  usually  intensified  by  firm  pressure  of  the  stetho- 
scope upon  the  chest.  When  the  chest  is  fixed,  especially  at  the 
lower  two-thirds,  and  the  ear  applied  over  the  seat  of  the  sound,  it 
will  be  found  to  have  disappeared.  This  sound  is  diagnostic  of  the 
first  stage  of  pleurisy. 

Moist  friction  sounds  are  produced  in  the  same  manner  as  those 
just  mentioned,  the  exudation  being  softened  in  character.  This 
sound  is  frequently  confounded  with  moist  bronchial  rales,  and  its 
discrimination  is  often  only  positive  by  a  careful  study  of  the  symp- 
toms and  concomitant  signs  present. 

Metallic  tinkling  is  a  sign  of  a  pneumo-hydrothorax  with  per- 
foration of  the  lung,  and  when  found  is  usually  diagnostic  of  this 
affection,  although  it  occurs  rarely  in  cases  of  phthisis  with  a  large 
cavity,  the  physical  conditions  for  its  production  being  similar  to  those 
in  pneumo-hydrothorax,  to  wit:  a  space  of  considerable  size  contain- 
ing air  and  liquid,  the  space  communicating  with  the  bronchial  tubes. 
It  consists  of  a  series  of  tinklin<^  sounds,  of  high  pilch,  silvery  or 
metaUic  in  tone,  and  is  very  well  imitated  by  dropping  a  small  marble 


DISEASES   OF  THE    RESPIRATORY  SYSTEM.  191 

into  a  metallic  vase.  It  occurs  irregularly,  not  being  present  with 
every  act  of  breathing,  and  may  be  produced  by  forced,  when  not 
heard  during  tranquil,  breathing. 

Were  it  not  for  the  location,  and  the  absence  of  concomitant  signs,  it 
might  be  confounded  with  tinkling  sounds  sometimes  produced  within 
the  stomach, 

THE  VOICE  IN  DISEASE. 

The  normal  vocal  resonance,  as  heard  over  the  third  rib  of 
the  chest  anteriorly  on  either  side,  may  have  its  intensity — 

1 .  Diminished  or  absent, 

2.  Increased  or  exaggerated. 

Or  its  resonance  may  be  of  the  character  of — 

3.  Bronchophony . 

4.  Pectoriloquy. 

5.  JEgophony. 

6.  Amphoric  voice. 

The  vocal  resonance  may  be  diminished  or  feeble  in 
bronchitis  with  free  secretion,  pleurisy  with  effusion,  or  in  complete 
consolidation  of  the  lung  structure  and  the  bronchial  tubes. 

The  vocal  resonance  is  absent  in  pneumothorax  and  in 
pleurisy  with  effusion. 

Exag'gerated  vocal  resonance  differs  from  the  normal  vocal 
resonance  in  a  slight  increase  of  its  density.  It  denotes  a  slight 
degree  of  solidification  of  lung  tissue,  and  is  chiefly  of  value  in  the 
diagnosis  of  tubercle. 

Bronchophony,  or  the  voice  concentrated  near  the  ear,  raised  in 
pitch  and  in  intensity,  denotes  complete  consolidation  of  the  pulmon- 
ary tissue  in  those  parts  in  which  the  sound  is  abnormally  present. 

Pectoriloquy  is  complete  transmission  of  the  voice  to  the  ear, 
the  articulated  words  being  distinctly  recognized.  It  has  a  close 
resemblance  to  the  resonance  heard  over  the  larynx  in  health.  Its 
presence  indicates  either  a  pulmonary  cavity  or  more  complete  con- 
solidation— in  other  words,  an  exaggerated  bronchophony. 

u^gophony  is  a  modification  of  bronchophony,  consisting  in 
tremulousness  of  the  voice,  its  character  nasal  or  bleating,  somewhat 
suggestive  of  the  cry  of  a  goat.  When  heard,  it  may  be  considered 
a  sign  of  pleurisy  with  slight  effusion,  or  of  pleuro-pneumonia. 

Amphoric  voice,  or  "the  echo,"  as  it  is  sometimes  called,  is  a 
musical  sound,  of  a  somewhat  hollow,  metallic  character,  like  that 


192 


PRACTICE  OF   MEDICINE. 


produced  by  blowing  into  an  empty  bottle.  It  is  sometimes  pro- 
duced in  large  cavities  within  the  lung,  but  is  especially  incident  to 
pneumothorax. 

Increased  bronchial  whisper  is  a  sound  in  which  the  whis- 
pered words  are  abnormally  intense,  and  higher  in  pitch  than  the 
normal  bronchial  whisper.  It  has  the  same  significance  as  exagger- 
ated vocal  resonance. 

SUCCUSSION. 

The  SUCCUSSion  or  splashing  sound  is  pathognomonic  of  one 
affection,  namely,  pneumo-hydrothorax. 

It  is  obtained  by  jerking  the  body  of  the  patient  with  a  quick,  some- 
what forcible,  movement,  the  ear  being  very  near  or  in  contact  with 
the  chest. 

The  sound  is  like  that  produced  when  a  small  keg  partially  filled 
with  liquid  is  shaken.  The  only  liability  to  error  is  in  confounding 
this  splashing  sound  with  that  sometimes  produced  within  the  stomach ; 
but  attention  to  concomitant  signs  and  the  symptoms  will  always  pro- 
tect against  this  error. 

ASSOCIATION   OF  THE   PHYSICAL   SIGNS   (dA   COSTA). 

"As  many  of  the  signs  elicited  by  the  various  methods  of  physical 
diagnosis  depend  on  the  same  physical  conditions,  they  may  be 
studied  in  groups.  The  following  will  be  usually  found  to  be  asso- 
ciated :" — 

Auscultation  Auscultation        Vocal 


Percussion. 


OF 

Respiration. 


OF  Voice. 


Fremitus. 


Physical  Conditions. 


Clear Vesicular  mur-   Normal     vocal   Unimpaired.    Lung     tissue     healthy     or 

mur     or     its       resonance.  nearly   so ;    at  any  rate, 

modification,  no     increased     density 

from  deposits,  etc. 


Dull, 


Bronchial,      or    Bronchophony.    Increased, 
harsh    respi- 
ration. 


Absent  respira-   Absent  voice. 
tion. 


Diminished 
or  absent. 


Solidification     of    pulmon- 
ary structure. 

Effusion  into  pleural  sac. 


Tympanitic...      Cavernous   or   Uncertain;  cav-   Uncertain;    Increased   quantity   of   air 


feeble,  ac- 
cording to 
cause. 


ernous  or  di- 
minished. 


mostl 
niin 


tly 
isli 


di- 
ed. 


Amphoric   or 
metallic. 

Cracked  metal 
sound. 


Amphoric    or  Amphoric     or  Mostly    di- 

metallic.  metallic.  minished. 

Cavernous  res-  Cavernous  res-  Uncertain, 

piration.  piration. 


vk^ithin  the  ghest,  due  to 
a  cavity  or  to  ovcrdistcn- 
tion  of  the  air  cells. 

Large  cavity  with  elastic 
walls. 

Generally  a  cavity  commu- 
nicating with  a  bronchial 
tube. 


DISEASES   OF  THE   NASAL   PASSAGES.  193 

DISEASES   OF   THE   NASAL   PASSAGES. 


ACUTE  NASAL  CATARRH. 

Synonyms.     Acute  rhinitis ;  acute  coryza;  "  cold  in  the  head." 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  (pituitary  or  Schneiderian  membrane)  lining  the  nose  and 
the  cavities  communicating  with  it ;  characterized  by  feverishness, 
feeling  of  fullness  and  discomfort  in  the  head,  and  attended  with  dis- 
charges of  fluid,  watery,  mucus,  or  muco-purulent  in  character. 

Pathological  Anatomy.  Hypercemia  of  the  mucous  mem- 
brane, attended  with  redness,  swelling  and  deficient  secretion.  This 
tumefaction  is  partly  increased  by  an  cedematous  infiltration,  causing  a 
quantity  of  colorless,  salty  and  very  thin  liquid  to  flow  from  the  nose. 
This  secretion  soon  assumes  the  character  of  thick,  tenacious  mucus 
or  muco-pus,  due  to  the  desquamation  of  the  epithelium  of  the  nasal 
mucous  membrane,  and  a  copious  generation  of  young  cells,  the 
hypersemia  and  the  swelling  of  the  membrane  diminishing. 

The  respiratory  portions  of  the  nasal  fossse  are  more  markedly 
affected  than  are  the  olfactory. 

Rarely,  and  then  in  new-born  infants  and  those  affected  with  the 
eruptive  fevers,  the  exudation  in  the  nasal  passages  is  of  a  fibrinous 
nature,  somewhat  similar  to  that  observed  in  diphtheria. 

Causes.  Atmospherical  changes  are  the  most  frequent  and  in- 
fluential. Exposure  of  the  neck  to  a  draught  of  cold  air,  or  of  the  feet 
and  ankles  to  cold  and  dampness,  or  changing  from  a  warm  to  a  cold 
atmosphere  suddenly,  are  among  the  most  usual  causes. 

Irritating  gases  and  vapors,  dust,  certain  powders,  as  ipecac  and 
tobacco,  excite  an  irritation  of  the  nasal  mucous  membrane.  The 
scrofulous  taint  and  the  rheumatic  diathesis  seem  to  render  the 
mucous  membrane  susceptible  to  frequent  attacks. 

Acute  coryza  is  usually  present  in  the  initial  stage  of  measles  and 
influenza. 

Epidemic  influence  occasionally  prevails  on  an  extensive  scale. 
The  poison  of  syphilis  or  the  use  of  the  iodide  of  potassium  not  un- 
frequently  act  as  exciting  causes. 

At  times  the  catarrh  seems  to  spread  by  contagion. 

Symptoms.  ' 'A  cold  in  the  head ' '  is  usually  preceded  by  a  feeling 
i6 


194  PRACTICE   OF   MEDICINE. 

of  lassitude  or  weariness  and  more  or  less  frontal  headache ;  then 
occur  irregular  chilly  sensatio7is  in  the  back,  followed  by  more  or  less 
feverishness  and  an  uncomfortable  feeling  of  dryness  in  the  nares, 
with  a  strong  inclination  to  sneeze.  This  is  soon  followed  by  an 
abundant  watery  and  saline  discharge,  which  is  continually  "dripping 
from  the  nostrils,  or  occasions  an  attack  of  sneezing  followed  by 
blowing  the  nose,  which  relieves  the  congested  and  swollen  mem- 
brane for  a  few  moments.  The  relief  is  temporary,  however,  the 
fuUess  of  the  head  and  difficult  obstructed  nasal  respiration  rapidly 
returning.  The  anterior  nares  are  red  and  i7ifla})ied,  and  the  eyes 
red  and  suffused  with  tears,  through  partial  or  entire  closure  of  the 
tear  ducts.  The  discharge  soon  assumes  a  purulent  character.  The 
voice  has  a  peculiar  tone,  rather  nasal  and  muffled  in  character. 
Within  a  few  days  the  swelling  subsides,  the  secretion  lessens,  health 
being  restored  in  about  ten  days  from  the  beginning  of  the  attack. 

When  the  attack  has  almost  terminated,  hard  crusts  may  form 
within  the  nostrils,  either  on  the  septum  or  turbinated  bones,  which 
are  with  difficulty  expelled  by  blowing  the  nose. 

Complications.  Irritation  and  swelling  of  the  upper  lip,  from 
repeated  blowing  of  the  nose  and  the  constant  contact  of  the  irritating 
discharge. 

Extension  of  the  catarrh  to  the  ethmoid  or  sphenoid  cavities  or 
frontal  simcs,  causing  increased  and  severe  frontal  headache ;  or  to 
the  antru7n  of  Highmore,  causing  tenderness  over  one  or  both 
cheeks. 

Extension  to  the  Eustachian  tube  and  middle  ear,  causing  impaired 
hearing;  or  to  the  pharynx  or  larynx,  causing  cough. 

Duration.  In  mild  cases  about  one  week  ;  severe  cases  continue, 
more  or  less  marked,  for  two  weeks. 

Prognosis.  Favorable  if  early  and  proper  treatment  be  insti- 
tuted;  if  neglected,  the  catarrh  tends  to  become  chronic.  In  very 
young  infants,  if  the  catarrh  is  not  rapidly  relieved,  loss  of  flesh  and 
strength  occur,  from  inabihty  to  take  the  breast. 

Treatment.  Attacks  the  result  of  atmospherical  causes  may  be 
aborted  by  the  early  administration  of  quinina  sulphas,  gr.  x-xv,  with 
morphincc  sulphas,  gr.  % ,  or  the  early  use  oi  pulvis  ipecacuanhcE  et 
opa,  gr.  V,  repeated  every  two  hours. 

The  following  errhi7ie  used  at  the  very  onset  has  proved  successful 
in  aborting  many  cases : — 


DISEASES   OF   THE   NASAL   PASSAGES.  195 

R .     Aluminis, 

Bismuthi  carb., 

Pulv.  talc, aa ^'  ^."^ 

Morphinse  hydrochlor., gr-  ij-  M. 

SiG. — Insufflate  one    powder  in  each   nostril  after    clearing  the   nose. 
(Sajous.) 

If  the  attack  has  already  developed,  relief  is  soon  afforded  by 
iinctura  belladonncB,  gtt.  ij,  every  hour  until  six  doses  are  taken,  after 
which  one  drop  every  two  or  three  hours  until  the  physiological 
actions  of  the  drug  are  produced;  if  much  fever  be  present,  iinctura 
aconiti,  gtt.  i-ij,  may  be  added;  or  the  following  combination  of  Dr. 
Sajous  :— 

R .     Ammonii  chlor., .    .    ^ij 

Tinct.  opii, ■n:\^xxiv 

Sacch.  alb., ^j 

Aq.  camphorse, ad  ...    .     f^^j.  M. 

SiG. — One  teaspoonful  in  water  every  hour  or  two. 

An  efficient  plan  of  treating  acute  coryza  is  by  producing  free 
diaphoresis  with  •'  Dover's  powder,"  gr.  x,  repeated  if  need  be, 
followed  by — 

R  .     Potassii  citratis, '^  ij-iv 

Syrupi  ipecac, 

Tinct.  opii  camph., aa ^ij-i^ 

Syr.  limonis, 'T^'w 

Aquae, ad ^iij.  M. 

SiG. — One  or  two  teaspoonfuls  every  hour  or  two. 

Attacks  of  acute  rhinitis  unaccompanied  by  febrile  reaction  are 
generally  promptly  aborted  by  a  four  per  cent,  solution  of  cocaine 
dropped  in  the  nostrils,  repeated  every  half  hour. 

With  either  of  the  above  plans  may  be  added  one  of  the  following 
errhines : — 

K.     Bismuth,  subnit.,     ...        ^vj 

Pulv.  acaciae, ^ij 

Morphinse  hydrochlor., gr.  ij-  M. 

SiG. — Every  hour  or  two.     (Ferrier.) 
Or— 

R.     Pulv.  cubebae, 5J 

Bismuth,  subnit., 5  ij 

Morphinse  muriat., g^-  ij.  M. 

SiG. — Used  by  insufflation  every  two  or  three  hours. 


196  PRACTICE   OF    MEDICINE. 

Or— 

B. .     Pulv.  fol.  belladonnae, ^  j 

Pulv.  morpbinre  sulph., K*"*  ij 

Pulv.  g.  acaciie, .  ad .^  ss.  M. 

SiG. — Use,    with    powder    blower,   to   anterior    and    posterior    nares. 
(Robinson.) 

Acute  coryza  occurring  in  infants  at  the  breast  is  controlled  by 
either  one  of  the  following  errhines  :  Throw  into  the  nose,  with  a 
powder  blower,  finely  powdered  saccJiariim  alba,  or  equal  parts  of 
finely  powdered  saccharum  album  and  camphora,  or  Robinson's 
errhine  of  saccharum  alba  and  camphora,  each  half  ounce  finely 
powdered,  and  acidum  taimictim,  gr.  xl. 

Attacks  of  nasal  catarrh  due  to  the  poison  of  syphilis  should  at 
once  be  placed  upon  the  proper  constitutional  treatment. 

Attacks  of  nasal  catarrh  associated  with  the  eruptive  or  mild  fevers 
require  no  special  treatment. 

It  is  well  to  remember  that  attacks  of  nasal  catarrh  occurring  in 
very  young  children  are  generally  the  result  of  hereditary  syphilis, 
and  should  be  treated  accordingly. 


CHRONIC  NASAL  CATARRH. 

Synonyms.     Chronic  rhinitis  ;  chronic  coryza. 

Definition.  A  chronic  inflammation  of  the  mucous  membrane 
lining  the  nasal  passages,  with  more  or  less  alteration  of  structure; 
characterized  by  a  sensation  of  fullness  in  the  nares,  increased 
secretion  and  a  perversion  of  the  special  sense  of  smell  and  of 
hearing. 

Causes.  The  result  of  repeated  attacks  of  the  acute  variety  ; 
inhalation  of  irritating  vapors  and  dust;  syphilis  and  scrofula. 

Pathological  Anatomy.  The  mucous  membrane  of  the  nares 
is  thickejied,  of  a  dark-red,  sometimes  grayish^  color,  the  superficial 
veins  dilated  and  varicose,  often  forming  polypoid  enlargements.  In 
many  cases  there  is  ulceration  of  the  structure,  with  more  or  less  loss 
of  substance;  the  secretion  is  thick,  tough,  of  a  greenish  character, 
and  often  very  fetid  ;  large  collections  of  dried  mucus  are  often 
formed  upon  the  turbinated  bones  and  septum. 

Symptoms.  A  feeling  oi  fullness  in  the  7iares,  increase  of  the 
secretion,  the  character  being  thick  and  greenish,  which,  dropping 


DISEASES   OF   THE   NASAL   PASSAGES.  197 

posteriorly  into  the  pharynx,  causes  paroxysms  of  "  hawking,"  which 
are  more  marked  in  the  morning  immediately  after  rising. 

The  special  se7ise  of  smeli  is  more  or  less  impaired,  and  in  many 
cases  entirely  abolished ;  the  special  sense  of  hearing  is  more  or  less 
diminished,  from  an  extension  of  the  inflammation  to  the  Eustachian 
tubes  ;  the  voice  has  a  peculiar  7iasal  intonation. 

An  almost  constant  &<}X\.  frontal  headache,  associated  with  a  feeling 
of  weio-ht,  showing  the  extension  of  the  disease  to  the  infundibulum 
and  frontal  sinus. 

Sudden  changes  of  temperature  cause  acute  exacerbation  of  these 
symptoms,  when  there  is  superadded  difficult  nasal  respiration. 

If  tdceration  of  the  nares  occur,  the  discharge  has  a  fetid  odor. 
This  condition  is  termed  ozcena. 

From  extension  of  the  inflammation  to  the  nasal  duct  or  its  ob- 
struction, the  tears  flow  over  the  malar  eminence  {epiphora^,  leading 
to  more  or  less  congestion  of  the  eyes. 

Diagnosis.  Hypertrophy  of  the  turbinated  bones  and  naso- 
pharyngeal catarrh  are  constantly  misnamed  chronic  nasal  catarrh. 
The  rhinoscope  readily  determines  the  diagnosis. 

Prognosis.  Permanent  cure  is  seldom  obtained,  the  disease 
being  so  decidedly  chronic  and  obstinate,  the  treatment  is  of  neces- 
sity protracted,  and  the  majority  of  patients  tire  of  it  before  a  com- 
plete cure  is  effected. 

Treatment.  If  it  depends  upon  diathetic  conditions,  the  cause 
must  be  ascertained  and  treatment  directed  accordingly. 

When  no  diathetic  cause  can  be  determined,  attention  should  be 
paid  to  the  general  health,  the  secretion  constantly  attended  to,  and 
the  diet  be  nutritious  and  digestible. 

Cleanliness  of  the  nasal  passages  is  of  the  utmost  importance, 
and  is  best  effected  by  the  post-nasal  syringe,  with  either  simple 
or  medicated  tepid  waters,  or  a  cleansing  solution,  such  as  Do- 
bell's,  to  wit : — 

Jj.     Acidi  carbolici, gr.  j 

Sodii  bicarbonat,, 

Sodii  borat , ,    .    .  aa gr.  v 

Glycerin], "Z] 

Aquae,  , Jj.  M, 

SlG. — As  a  spray  or  with  a  proper  syringe. 


198  PRACTICE   OF   MEDICINE. 

Or  "the  following  combination  of  Dr.  Sajous  : — 

R .     Sodii  bicarb., 

Sodii  bibor., ^9. gr.  viij 

Ext.  pinus  canad.  fld., V(\xv 

Glycerinoe, f  Zij 

Aquam, ad  .....  f^iv.  M. 

SiG. — Apply  with  atomizer  three  or  four  times  daily. 

After  which  decided  benefit  follows  the  use  of  one  of  the  following  : — 

R  .     Hydrargyri  chlor.  mite, 

Pulv.  aluminis,     ......  aa ^  ss 

Morphinae  hydrochlor., gr.  ij.  M. 

R.     Sodii  borat., 3J 

Bismuth,  subnit., ^ij 

Morphinae  muriat.,      gr.  j.  M. 

Or— 

R.     lodoformi, 3J 

Acid,  tannici,      gr.  v 

Pulv.  camphorae, ^j 

Bismuth,  subnit., 5J.  M. 

SiG. — To  be  used  by  insulation   or  as  a  snuff,  every  three  or  four 
hours. 

Or— 

R .     Ammonii  muriat., •    •    •    3J 

Glycerini, Zij 

Ext.  pinus  canad.  fld., i%\ 

Aquam, ad f.^ij-  M. 

SiG. — Five  to  ten  drops,  dropped  into  each  nostril  two  or  three  times  a 
day. 


DISEASES  OF  THE   PHARYNX. 


ACUTE  CATARRHAL  PHARYNGITIS. 

S37Tionyin8.  Catarrhal  tonsillitis ;  angina  catarrhalis ;  acute 
"  sore  throat." 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  tonsils,  uvula,  soft  palate  and  pharynx  ;  character- 
ized by  rigors,  fever,  painful  deglutition,  coughing,  or  constant  desire 
to  clear  the  throat,  with  a  more  or  less  decided  nasal  intonation  of  the 
voice. 


DISEASES   OF  THE   PHARYNX.  199 

Causes.  Exposure  to  cold  and  damp  ;  swallowing  hot  fluids  or 
food  ;  during  the  prevalence  of  scarlatina,  measles  or  variola. 

Pathological  Anatomy.  The  mucous  membrane  and  sub- 
mucous tissues  of  the  uvula,  soft  palate,  fauces,  tonsils  and  pharynx 
are  congested,  red  and  swollen,  the  secretion  is  at  first  lessened  or 
entirely  arrested  ;  later  it  is  increased,  but  of  a  thick,  tenacious,  opaque 
character.  The  swelling  is  most  evident  at  the  uvula,  due  to  the 
amount  of  relaxed  sub-mucous  tissue,  which  is  especially  thick  and 
long,  often  resting  on  the  root  of  the  tongue  ("  the  palate  is  down  "). 

Frequently  one  or  both  tonsils  are  swollen  to  such  an  extent  that 
the  fauces  are  completely  occluded,  and  the  condition  is  mistaken  for 
the  graver  phlegmonous  tonsillitis. 

In  severe  attacks  of  catarrhal  angina,  white  or  grayish-white  mem- 
branous masses  form  in  small,  irregular,  roundish  spots  on  the  red- 
dened mucous  membrane  of  the  tonsils,  soft  palate  and  pharynx, 
causing  the  affection  to  be  frequently  mistaken  for  diphtheria. 

Symptoms.  The  onset  is  usually  sudden,  with  rigors,  fever, 
thirst,  headache,  loss  of  appetite,  coated  tongue,  bad  taste,  foul 
breath,  dryness  in  the  throat,  painful  deglutition,  and  constant  desire 
to  clear  the  throat,  due  to  the  increased  length  of  the  uvula  ;  as  the 
inflammation  proceeds  the  secretions  are  increased,  the  fluid  often 
filling  the  mouth  and  also  causing  a  constant  desire  to  swallow,  each 
act  being  associated  with  acute  pains.  Not  infrequently  earache  adds 
to  the  patient's  distress,  from,  extension  of  the  "  catarrh"  to  the  Eus- 
tachian tubes  and  tympanum. 

In  severe  attacks  of  catarrhal  pharyngitis,  cases  which,  from  the 
intense  hyperaemia,  have  been  termed  erysipelatous  or  erythematotis 
pharyngitis,  the  muscles  of  the  palate  are  infiltrated  with  serum, 
which  greatly  interferes  with  their  function.  Under  normal  conditions 
the  contraction  of  the  muscles  of  the  anterior  half  arches  of  the  palate 
prevents  the  return  of  the  food  and  drink  into  the  mouth ;  while  the 
contraction  of  the  muscles  of  the  posterior  half  arches,  together 
with  the  uvula,  closes  the  passage  to  the  nose;  if  the  function  of 
these  muscles  be  impaired,  fluids  would  be  driven  through  the  nose 
or  back  into  the  mouth  by  the  contraction  of  the  pharynx  in  the  act 
of  deglutition. 

In  all  affections  of  the  pharynx  a  nasal  tone  is  pathognomonic, 
especially  if  the  muscles  of  the  half  arches  are  interfered  with. 

Varieties.     Exanthematous  Pharyngitis  is  the  form  of  the  affec- 


200  PRACTICE   OF   MEDICINE. 

tion  complicating  the  acute  infectious  diseases,  such  as  scarlatina, 
measles  aad  smallpox. 

Erysipelatous  Pharytigitis  is  the  form  complicating  facial  erysipelas ; 
rarely,  however,  the  affection  begins  in  the  pharynx,  spreading  to  the 
face  and  other  parts. 

Gangrenous  Pharyngitis  may  occur  with  diphtheria,  scarlatina, 
erysipelas,  smallpox  and  typhoid  fever.  The  symptoms  assume  a 
typhoid  (depressed)  character,  the  termination  being  usually  fatal. 

P/i/egmonous  Pharyngitis  is  the  variety  in  which  is  present  an  accu- 
mulation of  pus  in  the  submucous  and  deeper  tissues  of  the  pharynx, 
constituting  a  retro-pharyngeal  abscess.  This  variety  of  pharyngitis 
may  follow  the  penetration  of  a  sharp  piece  of  bone  or  be  secondary 
to  caries  of  the  cervical  vertebrae. 

Fibrinous  Pharyngitis,  or,  as  it  is  sometimes  termed,  pseudo-mem- 
branous, is  considered  with  croup  and  diphtheria,  of  which  it  consti- 
tutes a  part. 

Diagnosis.  On  account  of  the  great  swelling  of  the  tonsils,  it  may 
be  mistaken  iox  acute  tonsillitis;  but  the  mild  inflammatory  symp- 
toms should  prevent  the  error. 

Cases  with  membranous  deposits  on  the  tonsils,  soft  palate  and 
pharynx,  are  no  doubt  often  misnamed  diphtheria  ;  the  marked  dif- 
ference in  the  constitutional  symptoms  should  prevent  the  error. 

Prognosis.  Favorable,  the  affection  terminating  in  three  or  four 
days  by  the  raising  of  a  quantity  of  thick,  opaque  mucus. 

Treatment.  Perhaps  the  most  successful  treatment  of  this  affec- 
tion is  by  insufflation,  every  hour  or  two,  with  sodii  bicarbonas. 

Tinctura  opii,  n^v-x  for  a  dose  or  two  at  the  very  onset  of  an  attack, 
will  often  abort  the  catarrh. 

If  the  inflammatory  symptoms  are  severe,  ti?ictura  aconiti,  gtt.  j-ij, 
at  short  intervals,  is  of  decided  advantage.  At  times  tinctura  bella- 
donjicB  may  be  added. 

Locally,  cocaine  painted  over  the  inflamed  parts,  of  the  strength  of 
a  four  per  centum  solution,  or  used  in  the  form  of  lozenges,  is  a  valu- 
able remedy.  Holding  small  pellets  of  ice  in  the  mouth  is  useful,  as 
is  the  application  of  cither  heat  or  cold  to  the  angles  of  the  jaws. 
Gargles  or  sprays  of  aluminis  (gr.  viij-aquae  f^j),  afnmonii  murias 
(g.  xx-aquae  f3j).  or  potassii  chloras  (gr.  xij-aquae  f^j),  used  at  fre- 
quent intervals,  often  allay  the  congestion  and  consequent  swelling. 


DISEASES   OF   THE   PHARYNX.  201 

ACUTE  TONSILLITIS. 

Synonyms.     Amygdalitis  ;  quinsy  ;  phlegmonous  pharyngitis. 

Definition.  An  acute  parenchymatous  inflammation  of  one  or 
both  tonsils,  with  a  strong  tendency  toward  suppuration ;  character- 
ized by  moderate  fever,  pain  in  the  throat,  a  constant  desire  to  relieve 
the  throat,  painful  and  difficult  deglutition,  impeded  respiration,  and 
more  or  less  muffling  of  the  voice. 

Causes.  Generally  attributed  to  exposure  to  cold,  but,  in  the 
majority  of  cases,  the  exposure  is  so  slight  that  there  must  be  a  pre- 
disposition to  the  affection  ;  for  persons  once  affected  are  particularly 
prone  to  repeated  attacks,  upon  the  slightest  exposure. 

Pathological  Anatomy.  One  or  both  tonsils  will  be  seen,  on 
inspection,  to  project  from  its  bed,  as  a  rounded,  deep  red  body,  which 
may  even  extend  beyond  the  median  line,  when  they  may  entirely 
occlude  the  isthmus  of  the  fauces  ;  the  half  arches  and  posterior  border 
of  the  soft  palate  are  reddened  and  somewhat  swollen.  The  surface 
of  the  tonsils  is  often  covered  with  small,  yellowish  points,  which 
closely  resemble  patches  of  false  membrane,  but  careful  inspection 
will  show  that  they  are  beneath  the  mucous  membrane,  being  only 
the  distended  follicles  of  the  gland.  The  mucous  membrane  of  the 
fauces  and  pharynx  is  more  or  less  red  and  swollen. 

Symptoms.  Onset  more  or  less  sudden,  with  rigors,  rise  in  tem- 
perature, 102°  to  104°  Y.,  full,  frequent  pulse,  100  to  120,  headache, 
thirst,  pain  and  swelling  at  the  angle  of  the  jaw,  with  a  constant  desire 
to  clear  the  throat,  difficult  and  painful  deglutition,  from  the  enlarged 
tonsils  almost  closing  the  fauces,  when  the  respiration  is  more  or  less 
inipeded ;  the  voice  is  more  or  less  muffled,  and  attempts  at  phonation 
increase  the  pain. 

Darting  pains  along  the  Eustachian  tubes  are  of  frequent  occur- 
rence, the  patient  complaining  of  earache  and  more  or  less  deafness. 

If  suppuration  be  imminent,  the  throat  becomes  more  painful,  the 
character  of  the  pain  throbbing,  the  febrile  phenomena  increase,  with 
more  or  less  depression,  the  symptoms  seeming  to  be  of  great  danger, 
when  suddenly,  after  an  effort  at  vomiting,  or  spontaneously,  the  ton- 
sillar abscess  bursts,  a  quantity  of  pus  escapes  from  the  mouth,  and 
prompt  relief  follows. 

Duration.    The  disease  lasts  from  three  to  seven  days,  terminating 
either  by  suppuration  or  the  gradual  resolution  of  the  enlarged  glands. 
17 


202  PRACTICE    OF    MEDICINE, 

Diagnosis.  Tonsillitis  can  hardly  be  mistaken  for  any  other 
affection,  if  the  fauces  are  inspected. 

Prognosis.  In  the  majority  of  cases  the  result  is  favorable,  it 
very  rarely  proving  fatal,  except  in  children,  and  only  then  by  ob- 
structing the  respiration,  and,  at  the  same  time,  so  seriously  interfer- 
ing with  nutrition  that  the  child's  strength  fails. 

Treatment.  ''  Instar  specifici  in  hoc  inorbo  operatur''  well  said 
Holmes  when  referring  to  giiaiacuin  in  the  first  hours  of  a  true 
tonsillitis,  for  experience  has  amply  proven  its  power  to  cut  short  an 
attack  if  administered  early.  I  usually  order  tinctura  giiaiaci  aviino- 
niata,  foj,  in  water  or  milk  every  hour  or  two,  until  its  good  effects  are 
produced.  The  drug  is  all  the  more  successful  if  at  the  same  time  it 
be  used  locally  in  the  form  of  trochisctis  giiaiact  (aa  gr.  ij)  frequently 
repeated,  or  the  following  gargle  at  intervals  of  every  half  an  hour  to 
an  hour: — 

R  .     Tinctune  guaiaci  ammoniat., 

Tincturae  cinchonae  comp.,  .    .    .    .  aa  .    .    .    .f^ij 

Mel.  despumati, 3^j- 

M.  and  shake  together  until  the  sides  of  the  containing  vessel  are  well 
greased,  then 
Adde— 

Potassii  chlorat., 9^^ 

Aquae  destil., f^iv 

M.  and  add  gradually,  continuing  shaking. 

Should  the  febrile  reaction  be  high,  tinctura  aco?titim  small  doses 
frequently  repeated,  either  alone  or  alternating  with  guaiacum,  rapidly 
reduces  the  temperature  and  the  frequency  of  the  pulse,  and  by  its 
local  action  lessens  the  pain  and  swelling.  If  from  any  cause  the 
internal  use  of  aco7titum  be  contraindicated,  the  tinctura  aconiti  may 
be  diluted  w'lih.  glycerimctn  and  painted  over  the  affected  parts.  The 
author  has  seen  excellent  results  follow  the  use  of  sodii  salicylat.,  gr. 
x-xv  in  solution,  every  three  hours.  Prof.  Da  Costa  has  seen  attacks 
of  acute  tonsillitis  aborted  by  prompt  emesis  with  pulvis  ipecactiankcr, 
gr.  XX,  also  by  the  early  administration  of  qtiinina  sulphas,  gr.  xx  for 
an  adult,  or  gr.  viij  for  children. 

Cases  not  seen  until  two  or  three  days  after  the  onset  are  benefited 
by  the  following  : — 

li .     TinclurLc  ferri  chlor., f  .:^  ij 

Giycerini, ad  .    .    .    .    f  5  ij  M. 

Sio. — Teaspoonful  every  two  hours. 


DISEASES   OF  THE   LARYNX.  203 

This  palatable  mixture,  suggested  by  Dr.  Bosworth,  acts  as  a  local 
astringent  in  passing  over  the  inflamed  tonsils,  and  should  not  be 
followed  by  water  or  food  for  an  hour  at  least, 

Scarificatio7i,  a  long,  sharp  bistoury  being  used  to  make  five  or  six 
cuts,  affords  great  relief  when  the  tonsils  are  much  inflamed  ;  the  ex- 
ternal ws^  oi  ice  over  the  site  of  the  glands,  and  small  pellets  allowed 
to  dissolve  in  the  mouth,  afford  great  relief.  If  the  application  of 
cold  be  objectionable,  heat  m.ay  be  substituted  in  the  form  of  warm 
compresses  or  poultices. 

In  all  cases  we  must  also  have  recourse  to  such  general  therapeutic 
measures  as  are  calculated  to  guide  the  morbid  action  to  a  favorable 
issue  ;  the  bowels  should  be  kept  open  and  the  skin  and  kidneys  active  ; 
the  diet  should  be  in  the  shape  of  gruels,  as  it  is  impossible  for 
the  patient  to  swallow  any  solid  substance,  and  in  cases  where  even 
gruels  cause  painful  deglutition,  thin  oatmeal  gruel  can  be  used  with 
advantage. 

When  suppuration  cannot  be  averted,  hot  applications  should  be 
apphed  to  the  angles  of  the  jaws,  hot  gargles  and  the  steam  atomizer 
resorted  to,  medicated  with  opium,  belladonna,  benzoin  or  cocaine, 
and  as  soon  as  fluctuation  can  be  detected  the  abscess  should  be 
opened.  Also  during  this  stage  administer  qtiinince  sulphas,  gr,  iij-v, 
every  three  or  four  hours.  After  the  acute  symptoms  have  subsided, 
assist  the  return  of  the  glands  to  their  normal  condition  by  the  topi- 
cal application  of  cupri  sulphas  (gr.  xx-aquse  fjj)  or  liquor  fer^'i  sub- 
sulphaiis  (f^j-aquse  f^j). 


DISEASES  OF  THE  LARYNX. 


ACUTE  CATARRHAL  LARYNGITIS. 

Synonyms.     Catarrhal  laryngitis  ;  "  sore  throat." 

Definition.     An   acute   catarrhal   inflammation    of   the   mucous 

membrane  of  the  larynx  ;  characterized  by  feverishness,  diminished 

or  suppressed  voice,  painful  deglutition,  and  more  or  less  difficulty 

of  respiration. 

Causes.     Atmospherical  changes ;    cold  draughts  of  air  whether 

directly  inspired  or  exposure  of  parts  or  all  of  the  body  to  the  same. 


204  PRACTICE   OF   MEDICINE. 

Cold,  wet  feet ;  inhUation  of  irritating  vapors,  such  as  gas,  smoke  or 
ammonia ;  inhalation  of  dust.  Prolonged  efforts  at  public  speaking 
or  sinking  or  the  same  efforts  under  difficuldes.  In  children,  from 
violent  fits  of  crying. 

Pathological  Anatomy.  In  mild  cases  there  is  a  transient 
cono-fstion  (hypera^mia)  of  the  mucous  membrane  over  the  entire,  but 
more  commonly  circumscribed,  portions  of  the  larynx,  with  more  or 
less  swelhng  and  diminished  secretion  ;  the  mucous  membrane  soon 
returns  to  its  normal  condition,  the  secretion  being  slightly  increased. 

Symptoms.  The  attack  begins  rather  suddenly  with  a  feehng 
of  dryness,  rawness,  and  ticklhig,  referring  to  the  larynx,  with  the 
sensation  of  the  presence  of  a  foreign  body  in  the  throat,  and  with 
hoarsetu  ss  and  a  disposition  to  cough.  Deglutition  causes  pain  by  the 
upward  movement  of  the  larynx  and  by  the  pressure  of  the  food  on 
the  larynx  as  it  passes  along  the  gullet.  Attempts  at  speaking  are 
attended  with  more  or  less  distress  and  the  larynx  is  tender  on 
pressure. 

Coughing,  from  the  onset,  of  a  noisy,  har<:h,  hoarse,  or  toneless 
character  and  the  act  of  coughing  attended  with  a  sensation  of 
scratching  in  the  larynx.  The  first  day  or  two  there  is  scanty  expec- 
toration, but  in  a  short  time  the  secretion  is  increased,  giving  the 
cough  a  loose  character.  In  the  early  stages  the  sputa  may  be 
slighdy  streaked  with  blood.  Rarely  a  hemorrhage  occurs  from  the 
mucous  membrane  of  the  larynx.  The  voic  is  at  first  decidedly 
hoarse,  soon  followed  by  complete  aphonia.  The  respiration  is  but 
slighdy,  if  at  all,  affected  in  adfilts.  There  may  be  more  or  less 
febrile  reacdon.  In  children  the  onset  is  with  fiver,  white  coated 
t07igue,  frequent,  tense  pulse,  hot  skin,  ^r\d  flushed  face,  embarrassed 
respiration  ;  the  voice  hoarse  and  whispering  with  harsh,  ringing, 
croupy  cough  and  great  resdessness.  During  the  night  the  child  is 
subject  to  suffocative  attacks  (laryngismus  stridulus). 

Laryngoscopic  appearances.  These  vary  with  the  severity  of  the 
attack  and  the  stage  of  the  inspection.  In  mild  cases,  at  an  early 
period  the  mucous  membrane  presents  a  bright  red  appearance. 
Severe  cases  present,  in  addition  to  the  bright  redness,  the  mucous 
membrane  swollen,  to  such  an  extent  at  Umes  as  to  conceal  the 
vocal  cords,  they  appearing  only  as  slender  threads  of  a  reddish  tint. 
At  umes  the  mucous  membrane  presents  the  appearance  of  erosions 
or  ulcerations,  due  to  a  desquamation  of  the  epithelium. 


DISEASES   OF  THE   LARYNX.  205 

Duration.  Usually  about  one  week  ;  if  very  severe,  two  or  three 
weeks  may  elapse  before  the  larynx  returns  to  its  normal  condition. 

Prognosis.     Simple  catarrhal  laryngitis  never  terminates  fatally. 

Treatment.  Confinement  to  an  apartment  of  uniform  tempera- 
ture, the  air  kept  moist  by  the  vapor  of  water  being  disengaged  in  it, 
and  particularly  in  the  case  of  children. 

Locally,  a  hot  pack  should  be  kept  constantly  wrapped  about  the 
throat,  and  if  its  application  is  preceded  by  the  temporary  use  of  a 
weak  mustard  plaster,  the  relief  afforded  is  more  rapidly  obtained. 
At  the  very  beginning  of  an  attack  the  feet  should  be  placed  in  a  hot 
mustard  foot  bath,  and  a  saline  cathartic  administered. 

Prompt  action  on  the  skin  at  the  very  onset  will  frequently  shorten 
the  duration  of  a  catarrh  of  the  larynx.  Use  for  this  purpose  in  adults, 
pulvis  ipecacuanhcE  et  opii  (gr.  iij)  combined  with  potassii  nitras 
(gr.  iij)  every  three  or  four  hours.  If  there  be  much  febrile  reaction 
benefit  follows  the  use  of  tinctura  aconiti,  iU.j-ij.  every  half  hour  until 
five  or  six  doses  are  taken,  after  which  every  hour  or  two,  combined 
with  tinctura  opii,  ^]-v  ;  or  diaphoresis  may  be  produced  by  antimonii 
et  potassii tartras,  gr.  -io—^^,  every  hour,  or  by  a  hypodermic  injection 
oi  pilocarpus  murias,  gr.  i^. 

For  children,  several  doses  of  the  following  powder  a  couple  of 
hours  apart,  until  the  bowels  are  freely  moved : — 

R .     Hydrargyri  chloridi  mite, S^-  H 

Pulvis  ipecacuanhse, .    .    .  gr.  /^ 

Sacc.  lac, gr.  ij. 

to  be  followed  by  the  following : — 

li.     Potassii  citrat., ^iv 

Tinct.  aconiti, V(\iv 

Tinct.  opii  camphorat., ^  ij-iv 

Syr.  scillae, _:^  ij 

Syr.  tolu, ad ^iij.  M. 

SiG. — One  teaspoonful  every  two  hours. 

If  a  tendency  to  spasm  of  the  glottis  obtains,  full  doses  of  the  dro- 
mides  should  be  administered  at  once. 

Inhalations  from  the  onset  are  not  only  soothing  but  curative  in 
their  actions.     Either  of  the  following  are  recommended  : — 

U .     Infusi  humulus, Oj 

Vinegar, f^ss-j.  M. 

SiG. — Inhale  hot  every  hour. 


206  PRACTICE   OF   MEDICINE. 

R.     Tinct.  benzoin  comp., f3J~U 

Aquae  bull.,      Oj.  M. 

SiG. — Inhale  hourly. 

The  local  application  of  cocaine  is  of  great  benefit. 

Attacks  of  acute  laryngitis  occurring  from  efforts  in  public  speaking 
or  singing  are  wonderfully  benefited  by  the  use  of  acidiim  7iitricum 
dilutum,  Tt\,ij-v,  every  hour  or  two. 

The  patient  should  abstain  altogether  from  the  use  of  the  voice  and 
from  taking  food  or  drink  of  an  irritating  character. 


GEDEMATOUS   LARYNGITIS. 

Synonym.     CEdema  of  the  glottis. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  larynx  and  that  about  the  glottis,  with  an  infiltration  of  the  areolar 
tissue  by  a  serous,  sero-purulent  or  purulent  fluid ;  characterized  by 
obstructed  or  stridulous  breathing  and  dysphonia  or  aphonia. 

Causes.  The  result  of  acute  laryngitis  ;  abscess  in  or  about  the 
throat  or  tonsils ;  erysipelas  of  the  face ;  scarlatina ;  smallpox ; 
Bright's  disease.     Rare  in  children. 

Patholog'ical  Anatomy.  Infiltration  into  the  loose  connective 
tissue  of  the  ary-epiglottic  folds,  the  glosso-epiglottic  ligament,  the 
base  of  the  epiglottis,  and  the  inter-arytenoid  space.  If  the  true 
vocal  cords  are  inflamed,  their  color  changes,  and  instead  of  appear- 
ing white,  glistening  and  brilliant,  they  are  dull,  grayish-red  or  violet- 
red  in  patches.  If  the  swelling  be  the  result  of  purulent  infiltration, 
the  parts  affected  present  a  deeply  congested  color,  with  here  and 
there  spots  of  a  yellowish  hue. 

Serous  infiltration,  sufficient  to  cause  fatal  oedema,  disappears 
with  death,  leaving  but  slight  traces  to  account  for  the  formidable 
symptoms. 

Symptoms.  The  onset  is  much  the  same  as  a  simple  catarrhal 
laryngitis  with  a  gradually  increasing'  impedi?neni  to  the  respiration. 
The  patient  experiences  the  sensation  of  a  foreign  body  in  the  throat, 
and  after  a  short  time  a  dijfficulty  of  breathing,  which  ultimately 
threatens  suffocation.  The  deglutitio7i  is  rendered  difficult,  owing  to 
the  swelling  of  the  epiglottis  ;  the  voice,  at  first  muffled,  gradually 
becomes  weaker  and  weaker,  until  finally  it  is  almost  extinct ;  the 
cough  at  first  is  dry  and  harsh,  but  as  the  infiltration  increases  it 


DISEASES   OF  THE   LARYNX.  207 

becomes  stridulous  and  suppressed ;  there  is  no  expectoration  except 
that,  after  great  effort  to  clear  the  throat,  a  httle  frothy  mucus  is  raised. 
The  difficiilty  of  respiration,  as  the  disease  progresses,  becomes  greater 
and  greater,  and  the  paroxysms  of  impending  suffocation  more  fre- 
quent. The  inspiration  is  accompanied  by  awhisthng  sound,  char- 
acteristic of  the  narrow  condition  of  the  glottis,  the  patient  sits  up  in 
bed,  his  mouth  open,  gasping  for  breath,  his  eyes  protruding,  the 
whole  body  trembling  with  intense  convulsive  movements,  and  after  a 
time  a  general  cyanosis  commences,  the  face  assuming  a  bluish  hue, 
all  these  symptoms  continuing  for  a  few  moments,  when  slight  relief 
occurs,  to  be  again  followed  by  another  paroxysm,  in  one  of  which, 
if  nature  or  art  does  not  afford  prompt  relief,  death  occurs  from 
asphyxia. 

A  physical  examination  of  the  parts  may  be  made  by  gently  pass- 
ing the  finger  into  the  throat,  when  the  epiglottis  may  be  felt  very 
much  thickened,  and  the  ary-epiglottic  folds  may  have  attained  such 
tumefaction  as  to  convey  to  the  finger  an  impression  similar  to  that 
which  is  given  by  touching  the  tonsils. 

Laryngoscopic  appearance.  The  mucous  membrane  has  a  bright 
red  appearance.  The  epiglottis  has  the  appearance  of  a  semi-trans- 
parent roll-like  body,  or  it  is  often  merely  erect  and  tense.  It  is  this 
condition  of  the  epiglottis  which  explains  the  pain  and  difficulty  in 
deglutition.     Rarely  the  vocal  cords  are  infiltrated. 

Diagnosis.  Any  disease  which  gives  rise  to  dyspnoea  may  sim- 
ulate cedematous  laryngitis,  but  the  history  of  the  case  and  the  laryn- 
goscopic examination  will  generally  furnish  conclusive  evidence  as  to 
the  real  nature  of  the  malady. 

Prognosis.  As  a  rule  unfavorable.  If  early  and  vigorous  treat- 
ment be  instituted,  recovery  is  possible,  but  without  it  death  is  the 
inevitable  result,  the  patient  dying  asphyxiated.  Even  when  local 
measures  have  removed  the  obstruction  to  free  respiration,  the  patient 
is  very  likely  to  perish  subsequently  from  exhaustion  or  blood  poison- 
ing, or  from  pneumonia  or  other  lung  complication.  The  duration  of 
infiltration  of  the  larynx  varies  from  a  few  hours  to  several  days. 

Treatment.  Prompt  local  treatment  must  be  adopted  in  order  to 
remove  the  laryngeal  obstruction.  Leeches  placed  over  the  sides  of 
the  larynx  in  mild  cases  may  effect  so  much  reduction  in  the  oedema 
as  to  render  the  subsequent  progress  of  the  case  free  from  danger. 

If  the  infiltration  has  already  occurred  and   is  slight  in  amount, 


208  .  PRACTICE  OF  MEDICINE. 

scarification ,  guiding  the  instrument  by  the  index  finger  of  the  oppo- 
site hand,  may  afford  rehef,  or  the  hypodermic  injection  of ///<?t7?r- 
pincE  anurias,  gr.  y^,  repeated,  may  lessen  the  swelHng. 

Niemeyer  recommends  \.\i&  persistent  wst  of  small  pellets  of  ice  swal- 
lowed or  held  far  back  in  the  mouth  till  dissolved,  early  in  the  attack. 
Trousseau  recommends  the  ijiJialation  or  spray  of  a  strong  solution  of 
aciduvi  tannicum.  Prof.  DaCosta  suggests  the  application  as  near  the 
seat  of  the  disease  as  possible  of  liquor  ferri  subsulphatis  (Monsel's 
solution),  full  or  half  strength.  Mackenzie  says  the  patient  should  be 
kept  constantly  under  the  influence  of  potassii  bromiduni. 

If  these  means  fail,  iracheotoiny  is  indicated  ;  ift  those  cases  of  sud- 
den and  rapid  infiltration  of  the  glottis  or  larynx  occurring  in  Bright's 
disease,  erysipelas  or  scarlatina,  and  especially  the  former,  trache- 
otomy should  be  perforined  at  once. 

In  all  cases  of  infiltration  of  the  larynx  stimulants  should  be  boldly 
administered  per  rectum,  if  stomachic  administration  be  impossible. 

If  the  infiltration  be  composed  of  pus,  quinitiCE  sulphas.,  gr.  v, 
every  four  hours,  and  stimulants  are  indicated. 

SPASMODIC  LARYNGITIS. 

Synonyms.  Spasmodic  croup  ;  false  croup  ;  catarrhal  croup  ; 
child-crowing. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  lar>'nx,  associated  with  spas?nodic  contraction  of  the  glottis ; 
characterized  by  paroxysmal  coughing,  difficulty  of  breathing  and 
attacks  of  threatening  suffocation. 

Mackenzie  describes  it  as  "  a  form  of  convulsion  occurring  in  ill- 
nourished  infants,  characterized  by  spasmodic  action  of  the  abductors 
of  the  vocal  cords,  and  in  severe  cases  by  spasm  of  the  diaphragm 
and  intercostal  muscles." 

Causes.  Delayed  or  difficult  dentition  ;  excesses  in  eating  and 
drinking ;  excitement ;  violent  emotion  and  atmospherical  changes, 
are  all  given  as  causes  for  simple  croup.     It  is  often  hereditary. 

Pathological  Anatomy.  Coiigestio7i  of  the  mucous  mem- 
brane of  the  larynx,  with  slight  swelling  and  deficient  secretion,  are 
the  only  changes  that  have  thus  far  been  noted. 

Symptoms.  The  attack  occurs  chiefly  during  the  Jiight,  the  child 
on  retiring  having  either  its  usual  health,  or,  perhaps,  being  a  little 


DISEASES   OF  THE   LARYNX.  ^  209 

feverish.  After  several  hours  of  sleep  the  child  is  suddenly  awakened 
by  2.  paroxysm  of  suffocation,  and  a  dry,  harsh,  ringing  cough.  After 
half  an  hour  or  an  hour  or  two  the  breathing  becomes  easier,  the  cough 
less  "  croupy,"  the  skin  is  covered  with  more  or  less  perspiration,  and 
the  child  falls  asleep.  The  next  day  there  is  present  cough  of  a  loose 
character,  the  respiration  being  about  normal.  If  no  treatment  be 
instituted,  the  same  phenomena  occur  on  the  second  night,  the  child 
being  apparently  well  during  the  second  day,  the  cough  being  less  in 
amount ;  phenomena  of  a  similar  character,  but  of  much  less  sever- 
ity, are  present  the  third  night,  after  which  the  disease  usually  dis- 
appears. 

If  the  symptoms  of  the  first  paroxysm  continue  pronounced  for 
two  or  three  days,  there  is  a  strong  probability  that  the  inflamma- 
tion may  become  fibrinous  in  character,  or  that  true  croup  may 
develop. 

Diagnosis.  The  symptoms  are  so  characteristic  that  it  seems 
impossible  for  the  affection  to  be  mistaken  for  any  other  disease. 

Prognosis.  Spasmodic  or  simple  croup  always  terminates  favor- 
ably. 

Treatment.  During  the  paroxysm,  the  child  should  at  once  be 
placed  in  a  hot  bath  and  hot  or  cold  compresses  wrapped  about  the 
throat.  These  means  should  be  preceded  or  followed  by  a  mild 
emetic.  The  late  Chas.  D.  Meigs  always  used  aluminis,  with  or  with- 
out syr.  ipecacuanhcB ;  Prof.  Barker  recommends  hydrargyri  sulphas 
fiava  (turpeth  mineral),  gr.  j-iij  ;  Prof.  DaCosta  suggests  the  cautious 
use  of  apojnorphia,  gr.  ^,  hypodermically.  A  favorite  remedy  for 
emesis,  in  Germany,  when  the  jaws  are  not  closed,  and  one  that  is 
highly  successful,  is  tickling  the  fauces  with  the  finger  or  a  feather 
until  vomiting  is  produced.  Inhalations  of  chloroformum  often  at 
once  relieve  the  spasms,  but  must  never  be  employed  by  non-profes- 
sional persons.  Having  by  any  of  the  above  means  broken  up  the 
attack,  nausea  and  diaphoresis  should  be  maintained  by  the  following 
combination  : — 

Ut .     Extract,  ipecacuanhae  fluid.,     .    , TTLxij-xxiv 

Tinct.  opii  camphoratae, f^ij-iv 

Liq.potassii  citratis, ad f^iij-  M. 

SiG. — One  teaspoonful  every  two  hours. 

To  ward  off  further  spasms,  no  one  remedy  equals  potassii  bromi- 
dum,  gr.  v-xv,  every  three  or  four  hours,  or  chloral,  gr,  v,  at  bedtime. 


210  PRACTICE   OF   MEDICINE. 

Mackenzie  advises  the  use  of  7nusk  during  the  attack  if  the  child 
can  swallow ;  and  if  not,  then  as  soon  as  the  child  can  take  it,  and 
continued  at  intervals  for  a  day  or  two.     His  formula  is  as  follows  : — 

B  .     Moscbi, gr.  iss 

Sacch.  alb., gr.  ij 

Pulv.  acaciae, gr.  ij 

Syr.  aurantii  flor., 

Aquam, aa  .    .    .    .  ad  .    .  ,:^j.  M. 

SiG. — A  dose. 

The  air  of  the  room  should  be  moistened  by  the  vapor  of  steam 
constantly  disengaged  in  it. 

After  the  attack  has  passed  off,  the  general  condition  of  the  child 
must  be  attended  to  ;  for  this  purpose  it  is  well  to  administer  a  dose 
of  hydrargyri  chloridiim  mite,  to  be  followed  by  a  dose  of  oleum 
ricini  or  jnagnesii  carbonas.  The  diet  must  be  regulated,  all  farina- 
ceous articles  being  absolutely  forbidden. 


CROUPOUS  LARYNGITIS. 

Synonyms.     Membranous  croup  ;  true  croup. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  larynx,  attended  with  the  exudation  of  a  tough  secretion — the 
false  membrane — and  the  occurrence  of  spasm  of  the  glottis  ;  charac- 
terized by  febrile  reaction,  frequent  ringing  cough,  dyspnoea,  with  loud 
inspiratory  sound,  and  altered  or  extinct  voice,  showing  a  strong  ten- 
dency toward  death  by  asphyxia. 

Causes.  A  disease  of  childhood,  most  common  in  strong,  vigor- 
ous, well-nourished  males.  Certain  families  present  a  strong,  heredi- 
tary tendency.     Most  common  during  a  humid  winter. 

We  cannot  assent  to  the  dictum  of  some  authorities,  that  laryngeal 
diphtheria  and  croupous  laryngitis  are  identical. 

Pathological  Anatomy.  Intense  hyperemia  of  the  mucous 
membrane  of  the  larynx,  associated  with  swelling,  oedema  and  marked 
redness.  There  soon  appears  on  the  surface  of  the  mucous  mem- 
brane a  grayish  pellicle,  rapidly  coalescing  and  becoming  thicker — 
the  opaqiie,  false  membrane — which  differs  in  extent,  thickness  and 
adhesiveness  in  different  portions  of  the  larynx.  In  all  cases  the 
false  membrane  is  found  on  the  vocal  cords  and  inner  surface  of  the 
epiglottis.     The    first  exudation  (membrane)  softens   by  the  scrum 


DISEASES   OF   THE   LARYNX.  211 

which  is  exuded,  and  is  then  mechanically  dislodged  by  acts  of 
coughing  or  vomiting,  but  is  followed  by  successive  deposits  upon  the 
mucous  membrane. 

When  the  false  membrane  is  detached  the  mucous  membrane  of 
the  larynx  is  found  unaffected,  so  far  as  the  loss  of  structure  is  con- 
cerned. Several  successive  crops  of  membrane  may  occur  after  the 
detachment,  or  it  may  entirely  cease  to  form  after  the  removal  of  the 
first  exudation. 

On  microscopical  exami?iation  the  false  membrane  is  found  to  be 
composed  of  a  fine  network  of  fibrillae,  holding  in  their  interstices 
leucocytes  of  an  albuminous  or  fibrinous  nature. 

The  false  membrane  may^  extend  into  the  pharynx,  but  especially 
is  it  liable  to  extend  into  the  trachea  and  bronchial  tubes,  and,  as  the 
inflammation  extends  downwaid,  the  character  of  the  exudation 
changes  from  fibrinous  to  muco-purulent. 

Symptoms.  The  onset  of  "true  croup"  is  either  suddenly,  by 
an  attack  of  spasmodic  croup,  or  gradually,  as  an  acute  catarrh  of 
the  larynx,  rapidly  increasing  in  severity,  with  a  feeling  of  heat  in  the 
throat,  huskiness  of  the  voice,  harsh  cotigh,  fever  dSidi.  thirst,  the  hoarse- 
ness soon  becoming  marked,  and  the  cough  }\2i\\ng2i  inetailic , ''  croupy'" 
character,  rapidly  changing  to  a  stridulotis ,  husky  sound  ;  every  few 
minutes  the  child  takes  a  sudden,  deep  stridulous  inspiration,  the 
voice  becoming  more  and  more  husky.  Difficulty  of  breathing  now 
follows,  the  child  is  unable  to  lie  down,  or  if,  exhausted  by  the  efforts 
at  inspiration,  it  is  quiet  for  a  moment,  it  soon  starts  up  in  fright, 
breathing  more  heavily,  with  a  shrill,  whistling  inspiration.  Soon, 
from  the  narrowing  of  the  glottis,  from  the  presence  of  the  membrane, 
the  expiration  becomes  difficult  and  noisy,  and  suffocatioji  seems  im- 
minent, from  the  paroxysmal  attacks  of  spasm  of  the  glottis,  when 
the  child  tosses  wildly  about,  tears  at  its  throat,  as  if  to  remove  some 
obstacle,  the  face  becoming  cyanosed,  the  alae  of  the  nose  working 
rapidly,  the  mouth  wide  open,  the  inspiratory  efforts  gasping,  the  body 
covered  with  a  profuse  sweat,  and  death  seems  imminent,  when  the 
spasm  is  relaxed,  air  enters  the  chest,  the  breathing  becomes  some- 
what easier,  and  the  child,  exhausted  and  partially  stupefied,  drops 
into  a  fitful  sleep  of  a  few  moments'  duration. 

The  suffocative  attacks  return  at  short  intervals,  or  there  occur 
decided  remissions  between  them,  considerable  portions  of  the  false 
membrane  being  expelled,  when  the  child  falls  into  a  refreshing  sleep. 


212  PRACTICE   OF   MEDICINE. 

In  those  cases  which  tend  to  a  favorable  termination,  the  appear- 
ance of  improvement  noted  between  the  suffocative  attacks  is  main- 
tained, the  paroxysms  of  suffocation  becoming  less  frequent,  the 
expectoration  of  membrane  more  marked,  the  difficulty  of  breathing 
lessens,  the  cough  looser,  the  voice  gradually  returning,  the  fever, 
which  has  been  more  or  less  high  during  the  attack,  disappearing. 

If,  instead  of  improvement,  the  case  tends  toward  a  fatal  termina- 
tion, the  suffocative  attacks  become  more  frequent,  expectoration  is 
absent,  the  voice  and  cough  inaudible,  although  the  efforts  at  speak- 
ing and  coughing  are  visible,  the  difficulty  of  breathing  continues,  the 
respirations  becoming  more  frequent  and  shallow,  but  without  whist- 
ling and  stridor,  cyanosis  deepens,  the  countenance  has  an  indiffer- 
ent, drowsy  and  stupid  look,  the  eyes  dull  and  nearly  closed,  with 
symptoms  of  depression,  the  pulse  rapid  and  weak,  the  surface 
covered  with  a  cold,  clammy  sweat,  the  extremities  cold,  stupor  and 
insensibility  more  marked,  the  child  dying  of  carbonic  acid  poisoning 
or  asphyxia. 

Duration.  The  duration  of  true  croup  is  about  one  week,  rarely 
continuing  ten  days. 

Diagnosis.  (Edema  of  the  glottis  may  be  mistaken  for  croup 
until  the  period  of  the  formation  of  the  characteristic  membrane. 
The  chief  points  of  distinction  from  the  onset  are,  however,  absence 
of  fever,  paroxysmal  attacks  of  difficult  respiration,  followed  by  a 
complete  return  to  the  normal  condition. 

Laryngeal  diphtheria  differs  from  true  croup  in  its  history,  its 
epidemic  character,  the  marked  depression,  even  before  obstruction 
of  the  larynx  produces  imperfectly  aerated  blood,  the  presence  of 
albumin  in  the  urine,  and  the  sequelae. 

Prognosis.  A  very  fatal  disease.  The  danger  is  great  in  pro- 
portion to  the  age  and  feebleness  of  the  child. 

The  unfavorable  symptoms  are  :  Loud,  stridulous,  inspiratory  and 
expiratory  sounds,  laborious  and  prolonged  expiration,  depression  of 
the  base  of  the  thorax  during  inspiration,  whispering  voice  or  com- 
plete aphonia,  congestion  of  the  face  and  neck,  stupor,  weak,  rapid 
and  irregular  pulse,  cold  extremities,  and  a  cold,  clammy  perspiration. 

The  favorable  symptojns  are :  Expectoration  of  false  membrane, 
decrease  of  the  stridulous  respiration,  voice  changing  from  whisper- 
ing to  hoarseness,  looseness  of  the  cough,  moderation  of  the  fever, 
and  an  improvement  in  the  general  condition. 


DISEASES   OF  THE   LARYNX.  213 

Treatment.  The  indications  for  treatment  are  to  detach  and 
remove  the  false  inejjibrane ,  to  prevent  its  formation,  to  prevent  the 
attacks  of  spasm  of  the  glottis,  and  to  maintain  the  strength. 

To  detach  and  remove  the  membrane  emetics  are  of  the  highest 
utility,  the  favorite  of  this  class  being  the  one  first  used  in  this 
disease  by  Dr.  Fordyce  Barker,  consisting  oihydrargyri  sulphas flava 
(turpeth  mineral),  gr.  ij,  for  a  child  of  two  years  of  age,  repeating  the 
dose  as  often  as  rendered  necessary  by  the  obstructed  breathing  ; 
but  the  unnecessary  administration  of  emetics  should  be  avoided,  as 
the  strength  of  the  patient  must  be  maintained. 

To  prevent  the  formation  of  the  membranous  exudation  a  number 
of  remedies  have  been  recommended  and  highly  lauded  by  their 
respective  proposers.  If  seen  early,  as  the  fever  and  husky  voice  are 
developing,  tinctura  aconiti,  ^}i-],  every  fifteen  minutes,  and  qui- 
nince  sulphas,  gr.  ij-v,  every  hour  until  cinchonism  is  produced,  are 
of  unquestionable  utility  ;  another  plan  strongly  urged  is  with  aminonii 
brojnidum  in  full  doses  alternated  with  quinijtcE  sulphas,  gr.  iij-v,  every 
three  hours  ;  still  another  and  popular  remedy  is  hydrargyrum,  which 
is  certainly  one  of  the  most  reliable  agents  we  possess  ;  it  may  be 
used  as  hydrargyri chloridum  corrosivum,  gr.  43" 2V'  every  two  or  three 
hours,  or  in  the  following  formula  : — 

R.     Hydrargyri  chloridi    mite,  ........  gr.  yi-}^-}^, 

Sodii   bicarbonat., gJ"-  ij 

Pulvis  ipecac, .    .  gr.  ^-^\.  M. 

SiG. — One  powder  every  two  hours. 

Prof.  DaCosta  suggests  either  of  the  following  combinations  : — 

R .     Antimonii  sulphurati, •    •  gr.  ^ 

Pulv.  opii  et  ipecacuanhae, gr-  /^  M. 

SiG. — In  powder  every  two  hours. 
Or— 

R .     Hydrargyri  chloridum  mite, S^-  }4 

Pulv.  opii  et  ipecacuanhae, gr.  /^  M. 

SiG. — In  powder  every  two  hours. 

Antimonii  et  potassii  tartras,  a  remedy  that  some  years  ago  was 
popular  in  large  doses,  is  again  brought  forward  in  doses  of  gr.  -g\)-jV. 
QuinincE  sulphas,  gr.  v,  every  three  hours  until  six  doses  have  been 
taken,  if  given  before  the  exudation  has  formed,  it  is  claimed  will 
prevent  its  formation. 


214  PRACTICE   OF   MEDICINE. 

To  prevent  the  paroxysms  of  spasm,  small  doses  of  opium  in  the 
form  of  pulvis  ipecac  et  opii  (Dover's  powder),  or  full  doses  of  the 
bromides,  preference  being  given  to  ammonii  bromidum,  as  suggested 
by  Prof.  Bartholow,  on  account  of  its  being  "  eliminated  by  the  bron- 
chial and  faucial  mucous  membrane,  thus  acting  locally." 

To  maintain  the  strength  of  the  patient,  alcoholic  stitnulanis  in  full 
doses,  nutritious  but  easily  digested  aii??ient,  gui?ii7ia  in  tonic  doses, 
and  avimonii  carbonas,  are  particularly  indicated. 

Locally,  the  use  of  all  caustic  or  irritating  applications  to  the  fauces 
or  lar>'nx  is  emphatically  contraindicated. 

The  inhalation  of  the  vapor  of  slaked,  freshly  burned  lime  is  one 
of  the  most  ready  and  efficient  means  for  assisting  in  the  detachment 
of  the  false  membrane.  The  application  of  cold  or  hot  co7npresses, 
according  to  the  feelings  of  the  patient,  around  the  throat,  have  a 
strong  tendency  to  prevent  the  recurrence  of  the  spasms.  After  the 
formation  of  the  membrane,  great  relief  follows  the  use  of  the  vapor 
inhalations  and  oxygen  gas,  which  with  stimulants  and  liquid  nour- 
ishment may  safely  carry  the  patient  through  the  disease.  Cases 
in  which  the  membrane  presents  a  tendency  to  slowly  loosen  itself,  if 
the  patient's  strength  does  not  contraindicate  it,  are  greatly  benefited 
by  the  application  of  siyiapis,  or  even  small  flying-blisters,  to  the 
larynx. 

Niemeyer  advises  in  cases  showing  carbonic  acid  poisoning  from 
obstruction  of  respiration  due  to  accumulation  of  membrane,  the 
pouring  from  a  moderate  height  of  a  few  gallons  of  cold  water  over 
the  head,  nape  and  back  of  the  child  ;  the  shock  produced  always 
causes  it  to  revive  for  a  while,  and  to  cough  vigorously,  thus  expecto- 
rating large  quantities  of  the  membrane. 

Relief  from  the  obstructed  respiration  is  obtained  and  the  affection 
beneficially  influenced  by  the  use  of  "  O'Dwyer's  tubes." 

If  the  exudation  still  continues,  regardless  of  the  means  employed, 
the  propriety  of  tracheotomy  must  be  decided. 


LARYNGISMUS   STRIDULUS. 

Synonyms.  Spasm  of  the  glottis ;  pseudo-croup ;  "  Kopp's 
asthma." 

Definition.  A  temporary  spasm  of  the  muscles  of  the  larynx 
innervated  by  the  inferior  or  recurrent  laryngeal  nerves  ;  character- 


DISEASES   OF   THE   LARYNX.  215 

ized  by  a  sudden  development  of  dyspnoea  and  the  appearance  of 
deficient  oxygenation  of  the  blood. 

Causes.  Most  common  in  children,  the  result  of  teething,  laryn- 
gitus,  indigestion,  scrofula  or  other  cachexia.  Attacks  in  adults  are 
not  uncommon. 

Patholog'ical  Anatomy.  Death  the  result  of  spasm  of  the 
glottis  is  such  a  very  rare  occurrence  that  the  changes  in  the  larynx 
are  illy  understood. 

The  mechanism  consists  in  an  irritation  of  the  superior  laryngeal 
nerve — the  afferent  nerve — whose  function  is  to  supply  the  mucous 
lining  of  the  larynx  with  sensibility,  which  is  reflected  through  the 
inferior  laryngeal  nerve — the  efferent  nerve — the  motor  influence 
resulting  in  the  spasm  of  the  laryngeal  muscles. 

Symptoms.  The  spasm  of  the  laryngeal  muscles  is  of  sudden 
onset,  and  usually  after  nightfall.  The  child  may  have  been  in 
perfect  health,  to  all  appearances,  on  retiring,  or  it  may  have  shown 
symptoms  of  catarrh  of  the  upper  air  passages,  or  been  suffering 
from  gastro-intestinal  or  dental  irritation. 

The  child  awakes  suddenly,  coughing  in  a  metallic,  resonant  tone — 
the  croupy  cough — and  with  great  dyspncea,  with  loud,  crowing,  stridu- 
lus inspirations,  the  result  of  narrowing  of  the  larynx  from  spasm, 
with  wheezy,  stridtdous  expirations. 

The  entrance  of  air  is  so  greatly  obstructed  that  all  the  accessory 
muscles  of  respiration  are  called  into  use,  the  lips  and  finger  nails 
become  blue,  the  surface  cold,  the  countenance  anxious,  and  the 
inferior  portion  of  the  chest  is  drawn  in,  instead  of  being  expanded, 
during  inspiration.  General  convulsions  occur  at  times,  during  a  par- 
oxysm, also  strabismus,  and  involuntary  discharge  of  the  fasces  and 
the  urine. 

The  paroxysm  continues  from  half  an  hour  to  an  hour  or  more,  to 
return  after  a  few  hours'  sleep,  or  during  the  following  night  ;  the 
cough,  during  the  day,  has  the  croupy  character. 

Diagnosis.  The  non-febrile  and  distinctly  intermittent  nature  of 
the  affection  differentiates  it  from  croup,  and  its  own  distinctive  char- 
acters, from  all  other  diseases. 

Prognosis.  Favorable.  Death  from  suffocation  during  the  par- 
oxysm may  occur  in  very  young  children,  but  it  is  certainly  a  very 
rare  termination. 

Treatment.     For  the  paroxysm,  the  inhalation  of  a  few  drops  of 


216  PRACTICE   OF   MEDICINE. 

chl-oroforfnum  is  the  most  prompt  method,  due  care  being  exercised  ; 
complete  anaesthesia  is  unnecessary.  Success  is  reported  from  the 
prompt  inhalation  oi  amyl  nitris,  also  from  tiitro-glycerinum ,  in  small, 
but  frequently  repeated  doses  ;  the  following  combination  is  a  prompt 
antispasmodic  : — 

R  .     Potassii  bromidi, ^5  ij 

Chloral, ffr.  xxxij 

Syr.  aurantii  corticis, fjj 

Aqure  menth., f3J.  M. 

SiG. — One  teaspoonful  every  half  hour. 

After  the  paroxysm  has  been  suspended  by  the  above  combination, 
the  tendency  to  a  recurrence  of  the  attacks  is  obviated  by  the  steady 
and  continued  use  o{ potassii  bromidum,  in  moderate  doses.  Emetics 
are  often  useful  in  suspending  an  attack,  especially  if  it  be  due  to 
indigestion. 

Locally,  the  hot,  alternating  with  the  cold,  pack,  should  be  con- 
stantly applied  to  the  throat. 


DISEASES  OF  THE  BRONCHIAL  TUBES. 


ACUTE  BRONCHITIS. 

Synonyms.  Bronchial  catarrh  ;  acute  bronchial  catarrh  ;  "cold 
on  the  chest." 

Definition.  An  acute  catarrhal  inflammation  of  the  bronchial 
tubes  of  the  larger,  middle  and  third  size  ;  characterized  by  fever, 
sub-sternal  pain,  a  feeling  of  thoracic  constriction,  oppression  in 
breathing,  and  at  first  scanty,  followed  by  more  or  less  profuse 
expectoration. 

Causes.  Most  frequent  in  childhood,  especially  during  the  period 
of  dentition,  when  there  exists  a  strong  tendency  to  catarrh  of  the 
mucous  membrane  in  general  and  of  the  bronchi  in  particular.  In 
old  age  the  predisposition  again  returns.  Inhalations  of  irritants,  such 
as  dust,  smoke  and  air  too  hot  or  too  cold.  More  common  in  cli- 
mates  characterized   by   considerable   moisture   of  the   atmosphere 


DISEASES   OF   THE   BRONCHIAL   TUBES.  217 

combined  with  a  low  temperature,  and  especially  where  there  are 
sudden  and  marked  variations. 

Patholog'ical  Anatomy.  Hyperczmia  of  the  mucous  mem- 
brane of  the  bronchial  tubes,  manifested  by  a  diffused  redness,  swell- 
ing, asdema,  and  diminished  secreiio7i  ;  this  is  followed  by  an  increased 
secretion  and  overgrowth  and  desquamation  of  the  epithelial  cells, 
together  with  a  copious  generation  of  young  cells,  the  expectoration 
then  becoming  of  a  yellowish  color.  As  a  result  of  the  hypersemia, 
rupture  of  the  capillaries  of  the  mucous  membrane  frequently 
occurs,  when  the  slight  expectoration  of  the  first  stage  is  streaked 
with  blood. 

In  cases  of  bronchitis  following  the  exanthemata,  or  in  scrofulous 
patients,  the  bronchial  glands  participate  in  the  inflammation,  they 
becoming  hyper^mic,  swollen  and  filled  with  secretion,  and  not 
unfrequently  the  glandular  elements  undergo  a  hyperplasia,  and 
finally  the  "  cheesy  "  degeneration. 

Symptoms.  The  invasioji  is  usually  characterized  by  the  occur- 
rence of  either  nasal  or  laryngeal  catarrh,  or  both,  the  patient  feeling 
chilly,  followed  hy  flushes  of  heat,  the  liinbs,  joints,  and  even  the  body, 
are  affected  with  paiii  of  an  aching,  contused  character,  and  with  a 
sense  of  fatigue  and  want  of  energy ;  there  may  be  a  furred  tongue, 
anorexia  and  constipation. 

In  nervous,  irritable  persons,  and  in  children,  there  may  be  slight 
delirium,  and  often  in  very  young  children,  especially  during  the 
period  of  dentition,  convulsions  may  usher  in  an  attack. 

After  a  day  or  two  of  these  initiatory  symptoms,  those  characteristic 
of  bronchial  catarrh  develop. 

Pain  is  experienced  beneath  the  sternum,  especially  toward  its  upper 
part,  of  a  raw,  burning  or  tearhig  character,  aggravated  by  a  deep 
inspiration  or  by  coughing ;  the  pain  also  radiates  toward  the  sides, 
following  the  course  of  the  primary  bronchial  tubes.^  Te7iderness 
over  the  sternum  is  often  experienced. 

Cough  from  the  onset,  at  first  in  paroxysms  of  a  hard,  dry  charac- 
ter, changing  as  the  disease  progresses,  and  becoming  looser,  fol- 
lowed by  free  expectoration.  The  expectoratioji  at  first  is  small  in 
quantity,  almost  transparent,  frothy,  and  having  a  salty  taste,  often 
streaked  with  blood.  As  the  disease  progresses  it  becomes  more 
abundant,  of  a  yellowish  or  a  greenish-yellow  color,  and  of  a  tenacious 
consistency. 
iS 


218  PRACTICE   OF   MEDICINE. 

There  are  present  slight  fever,  hot,  dry  skin,  frequent //^Av,  loss  of 
appetite,  moderate  thirst  and  constipatioti. 

A  feehng  of  languor  and  weariness,  and  often  considerable  depres- 
sion, quite  out  of  proportion  to  the  febrile  state,  are  not  infrequent. 

Percussion.  Xormal,  except  in  those  rare  cases  in  which  the 
bronchial  glands  are  involved,  when  irregular  spots  of  dullness  can  be 
developed. 

Auscultation.  First  Stage  :  The  bronchial  mucous  membrane 
being  swollen  and  dry , the  respiratory  murmur  is  harsh  or  vesiciilo-bron- 
chial  in  character,  associated  with  diffused  sonorous  and  sibilant  rales. 

Second  Stai^e  :  The  secretion  from  the  bronchial  mucous  membrane 
being  increased,  the  respiratory  murmur  is  /ess  harsh  in  character, 
but  is  associated  with  /aro^e  and  small  moist  or  biibblinsc  rales. 

Diagnosis.  The  points  of  resemblance  and  difference  between 
acute  bronchitis  and  other  diseases  of  the  chest  will  be  pointed  out 
when  those  affections  are  described. 

Prognosis.  Acute  bronchitis  of  the  larger  tubes  usually  termi- 
nates in  complete  resolution  within  two  weeks.  In  children  and  in 
the  aged,  the  course  is  more  protracted,  and  the  symptoms  more 
severe,  but  recovery  is  the  rule. 

Treatment.  During  the  invasion,  quini?ice  stilphas,  gr.  x,  com- 
bined with  jEorphincB  sjilph.,  gr.  ye,  will  usually  prevent  or  abort  an 
attack  of  acute  bronchitis. 

In  \h.Q  first  stage,  in  adults,  when  the  mucous  membrane  is  swollen 
and  dry,  either  of  the  following  prescriptions  will  give  prompt  relief : — 

R  .     Antimonii  et  potassii  tart., gr.  ij 

Liquor,  ammonii  acetatis, f,^  iv 

Spts.  aetheris  nitrosi, f ^j 

(Tinct.  aconiti,  if  indicated), f.^ss 

Syr.  simplicis, ad ^S^j-  M. 

SiG. — One  teaspoonful  every  two  or  three  hours. 

Or- 

U  .     Vini  ipecacuanha, f  _:^  ij 

Liq.  jxjtassii  citrat., f  5v 

Syr.  acaciie, f^j.  M. 

SiG. — Tablespoonful  every  two  or  three  hours. 

If  the  cough  of  the  dry  stage  be  severe,  or  if  looseness  of  the  bowels 
follow  the  use  of  either  of  the  above  combinations,  tinctura  ofiii  cam- 
phorata  may  be  added  with  advantage. 


DISEASES   OF  THE   BRONCHIAL  TUBES.  219 

For  young  children,  the  above  in  proportionately  reduced  doses,  or 
the  following  : — 

R  .     Pulv.  ipecac  et  opii, gr.  x 

Pulv.  scillae, gr-  xij 

Hydrargyri  chlor.  mite, gr.  iv 

Sacch.  lact , gr.  x. 

Ft.  chart.  No.  xij. 

SiG. — One  every  two  hours. 

Locally  :  Hot  mustard  foot  bath,  and  sinapis  or  terebinihina  stupes 
over  the  chest,  the  patient  being  confined  to  an  apartment  in  which 
the  air  is  moistened  by  the  vapor  of  hot  water. 

Second  Stage :  The  secretion  of  the  bronchial  mucous  membrane 
being  copious,  marked  benefit  follows  the  use  of  the  following  com- 
bination by  Prof.  H.  C.  Wood  : — 

R .     Ammonii  chloridi, 

Ext.  glycyrrhizse, aa .^iss 

Glycerini, f^ss 

Mucil.  acacise, f^ij 

Syrupi  simplicis, 

Aquae, aa  ....  ad ^J"j-  ^• 

SiG.— Dessertspoonful  every  two  hours. 

Attacks  showing  a  tendency  to  linger  are  greatly  benefited  by  the 
following : — 

R  .     Terpine  hydrate, gr.  xlviij 

Glycerinse, q.  s.  sol. 

Syr.  laclucarii, ad f  J  ij-  M. 

SiG. — Teaspoonful  every  hour  or  two. 

During  the  attack,  attention  must  be  given  to  the  secretions  and  the 
diet  of  the  patient. 


CAPILLARY  BRONCHITIS. 

Synonyms.     Broncho-pneumonia  ;  "  suffocative  catarrh." 
Definition.     An    acute   catarrhal  inflammation    of  the  termifial 
bronchiajhtjjbes,  or  bronchioles  ;  characterized  by  fever,  impeded  and 
increased_  respiration,  impeded  circulation,  sligh^ough  and  scanty 
expectoration.  "" 

Causes.     Most  common  in  childhood,  following  exposure  to  cold 


220  PRACTICE   OF   MEDICINE, 

or. sudden    changes   of   temperature;    associated  with  measles  and 
whooping  cough. 

Pathological  Anatomy.  H}^^er^jnia,  redness  and  swellirig  of 
the  Hning  membrane  of  the  bronchioles,  with  the  exudation  of  a_tou^h, 
tenacious  secretion. 

The  air  vesicles  may  remain  unaffected,  but  in  the  rrmjorit^_ofcases 
they  are  involved,  producing  the  complication  known  as  "  catarrhal 
pneunioniay 

In  those  cases  in  which  the  air  cells  are  not  involved  in  the  inflam- 
matory changes,  the  air  passes,  during  the  act  of  inspiration,  through 
the  secretion  blocking  the  smaller  tubes,  but  is  prevented  from 
escaping  during  the  act  of  expiration,  the  secretion  in  the  smaller 
tubes  acting  as  a  valve  ;  the  result  is  distention  of  numerous  vesicles, 
producing  a  circumscribed  or  diffused  futicHonal  emphysema.  If  the 
secretion  produces  complete  closure  of  any  of  the  smaller  tubes,  the 
air  previously  drawn  into  the  vesicles  will  be  absorbed,  causing 
collapse  (atelectasis). 

If  the  inflammation  extends  to  the  alveoli  of  the  lungs,  it  produces 
the  condition  known  as  bro7icho-p7ieumonia,  a  frequent  complication  in 
children  and  feeble  elderly  people  ;  it  is  most  commonly  lobular  in 
character,  whence  the  term  "  lobular  pneu7nonia'' 

Symptoms.  Usually  preceded  by  more  or  less  ordinary  bron- 
chitis, followed  by  rise  of  temperature,  102-103°  F.,  difficult  7\.nd 
increased  respiratio7i,  with  paroxys77is  in  which  the  dyspnoea  is 
markedly  aggravated,  when  cyanosis  rapidly  develops. 

The  circulation  through  the  lungs  is  impeded  by  the  dyspnoea,  the 
pulse  becomes  feeble  and  flickering,  and  there  results  general  con- 
gestion of  the  venous  system,  the  countenatice  livid,  the  lips  a7td nails 
blue,  the  surface  cold,  and  often  covered  by  a  clam77iy  perspiration, 
the  mind  dull,  and  in  children  stupor  and  convulsions  rapidly  super- 
vene, the  result  of  the  no7i-aeratio7i  of  the  blood.  The  cough  is  slight, 
but  of  a  suppressed  character,  the  expectoration  scanty.  When  cyan- 
osis occurs  the  cough  may  almost  entirely  cease  ;  expectoration  also 
ceases,  death  soon  following  from  ap7ia'a  and  depression. 

Percussion.  Normal,  except  over  those  portions  of  the  lungs 
which  are  in  a  condition  of  collapse,  when  dullness  rapidly  develops 
and  may  as  rapidly  disappear,  changing  to  other  portions  of  the 
lung. 

Auscultation.       First  stage,   harsh  or  vesiculo-bronchial,  soon 


DISEASES   OF   THE   BRONCHIAL  TUBES.  221 

followed  by  dhmnished  respiratory  muri7iur,  associated  with  sub- 
crepita7it  rales. 

Diagnosis. — Capillary  bronchitis  is  often  mistaken  for  true 
catarrhal  pneumonia,  the  points  of  distinction  between  which  will  be 
pointed  out  when  discussing  that  affection. 

Prognosis.  In  children,  on  account  of  their  inability  to  expecto- 
rate, which  tends  to  rapid  collapse  of  the  lungs,  and  in  the  aged,  the 
prognosis  is  most  grave.  In  the  strong  and  vigorous  recovery  follows 
prompt  and  energetic  treatment. 

Treatment.  From  the  very  onset  of  the  attack  the  treatment 
must  be  supporting,  with  the  addition  of  such  measures  as  seem  to 
possess  a  controlling  influence  over  the  catarrhal  process. 

The  patient  must  be  confined  to  bed,  well  covered  and  the  tem- 
perature varying  between  75°  and  80°,  the  air  moistened  with  steam. 
In  the  first  stage  dry  cups,  mild  smapis  applications  or  terebinthina 
stupes  should  be  applied  to  the  chest,  after  which  it  should  be  covered 
with  an  oil-silk  jacket  or  the  jacket  poultice,  if  the  child  be  not  too 
young  to  permit  so  heavy  an  application  without  adding  to  the  distress 
in  the  breathing. 

The  diet  must  be  of  the  most  nutritious  character,  the  great  aim 
being  to  sustain  the  powers  of  life  until  the  catarrhal  process  has 
passed  through  its  different  stages,  hence  milk,  eggs,  chicken,  mutton 
and  beef  broths,  with  the  free  use  of  stimulants,  commenced  early 
and  in  amounts  large  enough  to  overcome  the  signs  of  depression 
which  are  present  early  in  the  attack. 

If  the  fever  be  high,  over  102°  F.,  quinincB  sulphas  is  indicated  in 
full  doses,  for  a  child  ;  either  in  suppository  or  the  following  : — 


R .     Quininas  sulphatis, '^'■^ 

Acid,  sulphurici  dilut., q.  s. 

Spts,  setheris  nitrosi,   , f^^iv 

Syr.  tolu., f.^^iv 

Aquae  menth.  p., f^j.  M. 

SiG. — One  teaspoonful  every  two  or  three  hours. 
Or— 

R .     Antipyrine, gr.  xxxij 

Sacch.  alb., f^^j 

Aq,  menth.  p., ^J 

Elix.  simplicis, ^^ij.  M. 

SiG. — One  teaspoonful  every  hour  or  two  till  four  or  five  doses. 


222  PRACTICE   OF    MEDICINE. 

For  the  catarrhal  process  either  of  the  following,  regulating  the 
dose  in  accordance  with  the  age  of  the  patient  : — 

R.     S>T.  ipecac, n\^v-xx 

Spts.  jetheris  nitrosi, TT\^v-xv 

Tinct.  opii  camp TT\^v-xx 

Tinct.  scillae, TT\^v-xx 

Liq.  potassii  citrat., n\^xl-5ij.        M. 

SiG. — Every  two  hours. 

Or— 

R.     Potassii  iodidi, gr.  ij-v 

Ammonii  carbonat., gr.  iij-v 

Syr.  glycyrrh., f.^ss 

Syr.  tolu, f^ss  M. 

SiG. — Every  two  or  three  hours. 

If  suffocation  is  imminent  the  use  of  e?netics  is  indicated  ;  the  most 
suitable  are  ipecacuanha  or  hydrargyri  sulphas  flava,  care  being 
taken  not  to  repeat  emesis  so  often  as  to  produce  exhaustion.  Prof. 
H.  C.  Wood,  in  desperate  cases  of  suffocative  catarrh,  advises  the 
alternate  use  of  the  hot  and  cold  douche  conjointly  with  stimulating 
remedies. 

CROUPOUS  BRONCHITIS. 

Synonyms.  Membranous  bronchitis  ;  plastic  bronchitis  ;  diph- 
theritic bronchitis. 

Definition.  An  acute  inflammation  of  the  mucous  membrane 
of  the  larger  and  middle-sized  bronchial  tubes,  attended  with  an 
exudation,  forming  a  membraniform  layer,  which  is  closely  adherent 
to  the  mucous  surface;  characterized  by  febrile  reaction,  cough,  diffi- 
cult breathing,  scanty  expectoration,  followed  by  the  expulsion  of  the 
false  membrane  in  the  form  of  patches  or  casts. 

Causes.  Associated  with  membranous  laryngitis  from  extension 
downward  ;  asthma;  emphysema  ;  phthisis  ;  but  most  commonly  the 
result  of  exposure  to  cold  and  damp,  in  those  of  strong  and  vigorous 
constitutions. 

Pathological  Anatomy.  Hypercemia  of  the  mucous  mem- 
brane of  the  bronchial  tubes,  associated  with  swelling  and  cedema, 
during  which  the  surface  is  covered  with  a  white  or  grayish-white, 
firmly  adherent,  membranous  deposit,  cemented  together  by  a  coagu- 
lable  exudation,  and  prolonged  by  rootlets  from  its   under  surface 


DISEASES   OF   THE    BRONCHIAL   TUBES.  223 

into  the  bronchial  follicles,  which  sooner  or  later  is  loosened  and  de- 
tached by  suppurative  process  and  is  expectorated  after  a  violent  fit 
of  coughing  or  vomiting.  When  expectorated,  the  false  jnembratie , 
as  it  has  been  termed,  has  either  the  form  of  patches  or  is  thrown  off 
entire  from  the  bronchial  tube,  and  may  be  found  to  consist  of  casts 
representing  more  or  less  of  the  bronchial  subdivisions,  and  present- 
ing an  appearance  not  unlike  "  boiled  macaroni." 

On  microscopical  exajjiination,  the  detached  membrane  presents 
fibrillae  which  characterizes  fibrine  or  lymph  in  other  situations,  and  if 
placed  in  a  solution  of  acetic  acid,  it  becomes  greatly  swollen,  while 
ordinary  mucus  contracts  and  becomes  more  dense  if  added  to  the 
same  solution. 

Symptoms.  There  are  no  symptoms  or  signs  by  means  of  which 
this  variety  of  bronchitis  can  be  distinguished  from  ordinary  catarrhal 
bronchitis,  prior  to  the  expectoration  of  the  false  nietnbrane. 

Expectoration  is  preceded  and  accompanied  by  violent  paroxysms 
of  coughing,  and  after  more  or  less  of  the  membrane  has  been  raised 
a  muco  purulent  expectoration,  streaked  with  blood,  may  be  present 
for  several  days. 

Duration.  The  inflammation  may  be  either  acute,  sub-acute  or 
chronic,  expectoration  of  patches  or  strips  of  the  membrane  being 
repeated  at  intervals  of  days,  weeks,  months,  or  even  years. 

Prognosis.  In  adults,  favorable,  if  not  associated  with  other 
grave  affections,  such  as  phthisis,  pneumonia  or  emphysema.  In 
young  children  it  may  cause  obstruction  to  the  respiration,  and  not 
unfrequently  proves  fatal. 

Treatment.  As  the  character  of  the  inflammation  can  seldom 
be  determined  until  the  membrane  or  portions  of  it  have  been  expec- 
torated, the  treatment  is  at  first  the  same  as  in  cases  of  ordinary  acute 
bronchitis. 

As  soon,  however,  as  the  character  of  the  inflammation  can  be  de- 
termined, acute  emesis  is  the  most  effective  means  of  removing  the 
obstruction  caused  by  the  false  membrane,  the  best  agents  of  this 
class  being  either  hydrargyri  sulphas  fiava,  ipecacuanha,  or  zinci 
sulphas,  to  be  repeated  as  indicated. 

Inhalations  of  the  vapor  of  water,  and  especially  of  lime  water,  are 
highly  serviceable. 

To  prevent  the  formation  of  membrane,  Prof.  Bartholow  strongly 
urges  the  use  of  ammonii  iodiduiii  and  carbonas  combined,  in  small 


224  PRACTICE   OF   MEDICINE. 

dpses  every  hour  or  two.     In  a  case  treated  by  the  author  after  this 
method,  excellent  results  followed. 

In  cases  showing  a  tendency  to  become  chronic,  good  results 
will  follow  the  application  of  flying  blisters  to  the  chest  and  the 
internal  administration  of  arsenicion  and  some  preparation  of  pix 
liquida. 

CHRONIC  BRONCHITIS. 

Synonyms.  Chronic  bronchial  catarrh  ;  winter  cough  ;  second- 
ary bronchitis. 

Definition.  A  chronic  inflammation  of  the  mucous  membrane  of 
the  larger  and  middle-sized  bronchial  tubes  ;  characterized  by  cough 
and  more  or  less  profuse  expectoration,  plus,  in  many  cases,  the 
symptoms  oi  emphysema  of  the  lungs,  which  complicates  the  majority 
of  cases. 

Chronic  bronchitis  may  be  either  primary  or  secondary. 

Causes.  Primary,  the  exposure  to  wet  or  cold,  or  the  repeated 
inhalation  of  dust,  vapors,  or  other  irritants.  Secondary,  due  to  gout, 
rheumatism,  syphilis,  cardiac,  renal  or  pulmonary  diseases,  or  alco- 
holism. 

Varieties.  I.  Mucous  catarrh,  associated  with  moderate  expecto- 
ration. II.  Bronchorrhcea,  profuse  expectoration.  III.  Dry  catarrh, 
scanty  expectoration.     IV.  Fetid  bronchitis. 

Patholog'ical  Anatomy.  The  mucous  membrane  of  the  bron- 
chial tube  is  discolored,  being  of  a  more  or  less  dull  red,  often  of  a 
deeply  venous  hue,  mingled  with  a  grayish  or  brownish  color.  These 
changes  may  be  either  in  patches  or  extensively  diffused.  The  ves- 
sels of  the  membrane  are  dilated.  The  mucous  membrane  is  thick- 
ened, resulting  in  the  reduction  in  the  calibre  of  the  tube  and  a 
roughening  of  its  internal  surface.  The  submucous  tissue  becomes 
infiltrated,  contracted  and  indurated. 

The  elastic  and  muscular  coats  of  the  tubes  become  hypertrophied, 
lose  their  elasticity,  and  the  cartilages  become  the  seat  of  calcareous 
deposits. 

As  the  result  of  the  loss  of  elasticity  and  muscular  tone  of  the  tubes 
they  become  irregularly  dilated,  "  bro?ichial  di/atation.''  The  dilata- 
tions may  be  uniform  in  character,  resembling  somewhat  the  fingers 
of  a  glove,  or  they  may  be  sacculated  or  globular,  forming  actual 
cavities  in  the  bronchial  structure. 


DISEASES   OF  THE   BRONCHIAL  TUBES.  225 

In  the  mucous  variety  the  secretion  consists  of  young  cells  and 
mucous  corpuscles,  having  a  yellowish  color  ;  in  the  dry  variety,  the 
"catarrh  sec  "  of  Laennec,  or  "  dry  bronchial  irritation,"  the  secre- 
tion is  scanty,  tough,  semi  transparent,  and  occurs  in  defined  globular 
masses;  in  bronchorrhcea,  which  is  usually  associated  with  bronchial 
dilatation,  the  secretion  is  abundant,  greenish  yellow  in  color,  and 
often  fetid. 

Symptoms.  The  most  characteristic  symptoms  of  chronic  bron- 
chitis are  the  cough  and  expectoration.  Unless  associated  with  other 
diseases,  the  general  health  suffers  but  little,  if  at  all,  constitutional 
symptoms  being  present  only  during  acute  exacerbations. 

Mucous  catarrh,  or,  from  its  occurring  most  commonly  during  the 
winter  months,  "winter  cough,"  is  characterized  by  paroxysms  of 
cough,  more  or  less  violent,  followed  by  the  expectoration  of  a  yel- 
lowish mucus. 

Dry  catarrh  is  characterized  by  a  harsh  cough,  a  feeling  of  sore- 
ness or  rawness  under  the  sternum,  and  the  expectoration  of  small 
globular  masses  ;  this  variety  occurs  with  emphysema,  gout,  rheuma- 
tism and  asthma. 

Bronchorrhcea,  which  is  associated  with  bronchial  dilatation,  and 
most  common  in  the  elderly,  is  characterized  by  paroxysms  of  severe 
coughing,  followed  by  the  copious  expectoration  of  greenish-yellow, 
often  fetid,  mucus  ;  the  amount  expectorated  often  amounts  to  four 
or  five  pints  in  the  twenty-four  hours. 

Fetid  bronchitis,  often  associated  with  bronchial  dilatation,  has  an 
excessively  fetid  odor  of  the  breath  and  expectoration.  The  decom- 
position of  the  secretion  may  cause  gangrene  of  the  bronchial  mucous 
membrane,  and  even  of  the  lung  structure. 

Percussion.  Unless  complicated  with  other  affections,  Jtormal ; 
bronchial  dilatation  occur,  there  are  diffused  spots  of  the  tyynpanitic 
or   amphoric    percussion     sound,    the    physical    condition    being   a 
circumscribed  cavity  containing  air  and   connecting  with    a   bron- 
chial tube. 

Auscultation.  Harsh  or  vesiculo-bronchial  respiration,  asso- 
ciated with  more  or  less  profuse,  sonorous,  sibilant,  and  large  and 
small  bubbling  rales  ;  in  bronchial  dilatation,  in  addition  to  the  harsh 
respiration,  is  found  broncho-cavernous  breathing,  with  large  and 
small  gurgling  rales. 

If  emphysema  complicate  chronic  bronchitis,  the  physical  signs  are 

19 


226  PRACTICE    OF   MEDICINE. 

somewhat  modified,  and  will  be  pointed  out  when  discussing  that 
affection. 

ProgTiosis.  If  unassociated  with  disease  of  the  lungs  or  heart, 
chronic  bronchitis  is  never  dangerous  to  life,  although  the  symptoms 
are  present  more  or  less  continually,  and  aggravated  upon  the  least 
exposure. 

If  associated  with  phthisis,  emphysema,  disease  of  the  heart,  or  of 
the  kidney,  the  prognosis  is  governed  by  those  affections. 

Treatment.  Cases  of  chronic  bronchitis,  of  whatever  variety, 
should  observe  the  following  general  rules  :  i.  Attention  to  the  gen- 
eral health.  2.  The  clothing  ;  wearing  flannel  the  year  round,  or, 
what  is  better,  silk  under-clothing,  taking  care  that  the  opposite 
extreme  of  too  much  clothing  be  not  practiced. 

The  medical  treatmefit  is  guided  by  the  cause,  character  zjidi  severity 
of  the  disease. 

If  secondary  to  other  affections,  in  the  majority  of  cases  remedies 
directed  to  the  bronchial  mucous  membrane  are  contra-indicated. 
If  the  result  of  the  rheumatic  or  gouty  diathesis,  in  addition  to  the 
remedies  directed  to  the  disease  itself,  should  be  combined  change 
to  a  warm  climate,  if  possible,  and  a  more  or  less  protracted  course 
oi potassii  iodidwn,  or  lithii  citras,  or  a  residence  at  one  of  the  alkaline 
springs. 

For  mucous  catarrh,  with  acute  exacerbations  : — 

R  .     Ammonii  chloridi, .^  ij 

Glycerini, ^%^^ 

Codeinse   sulph., ?,^-  /4 

Vini  picis, ^^"j 

Syr.  prun.  virg., f^iss.         M. 

SiG. — Tablespoonful  every  three  or  four  hours. 

Dry  catarrh  is  greatly  benefited  by — 

R .      Potassii  iodidi, gr.  v-x 

Elix.    cinchonoe, Ii^xx 

Villi  picis,  liq., ad  ...    .  ^j.  M. 

Three  times  a  day. 
Or— 

R.     Ext.  eucalypt.  fld., f,5J 

Ammonii  cliloridi, ,^  i j 

Ext.  glycyrrhi/se, ^ij 

Syr.  tolu, fo'jj-  M. 

SiG. — One  teaspoon  ful  every  three  or  four  hours. 


DISEASES   OF   THE   BRONCHIAL  TUBES.  227 

For  bronchorrhoea,  copaiba,  gtt.  v-x  every  three  hours,  or  spts. 
terebinthincB,  gtt.  v,  every  four  hours  or  acidiim  carbolicuni,  gr.  ss, 
four  times  a  day,  and  at  the  same  time  using  ol.  morrhticz  and 
arsenicum,  or,  if  these  means  fail,  inhalations  of  alwjien,  aciduin 
galliciiin  or  acidiim  iatinicuin. 

If  the  expectoration  be  fetid,  "fetid  bronchitis,"  Prof.  DaCosta 
recommends  the  internal  use  of  acidum  carboticum,  gtt,  j  every  third 
hour,  with  inhalatiotis  of  acidwn  carbolicum  (gr.  v,  aqua,  ^j)  two  or 
three  times  a  day. 

Locally,  irritation  with  tinctura  iodi,  or  flying  blisters,  repeated  once 
or  twice  weekly,  is  of  advantage. 


ASTHMA. 

Synonyms.     Nervous  asthma  ;  bronchial  asthma. 

DeJB.nition.  A  paroxysmal  spasmodic  contraction  of  the  muscular 
layer  surrounding  the  bronchial  tubes,  and  perhaps  associated  with  a 
tonic  spasm  of  the  diaphragm,  and  more  or  less  bronchial  catarrh ; 
characterized  by  spasmodic  attacks  of  great  dyspnoea,  continuing 
usually  for  several  hours. 

Causes.     A  true  neurosis  of  the  respiratory  apparatus. 

The  result  of  peripheral  or  local  disturbances  in  the  nervous  system, 
often  hereditary  ;  pressure  on  the  pneumogastric  nerve  ;  cardiac  dis- 
ease ;  gastric  catarrh  and  constipation,  resulting  in  irritation  of  the 
end  organs  of  the  pneumogastric ;  uterine,  hepatic,  or  nephritic  dis- 
ease ;  inhalation  of  various  substances,  as  ipecac,  turpentine,  or  irri- 
tating dusts  ;  climate ;  mental  and  moral  influences. 

Asthma  is  more  common  in  men  than  in  women  ;  in  childhood  and 
young  adults  than  those  of  middle  life  and  old  age  ;  in  the  well-to-do 
and  wealthy  than  in  the  poor. 

Symptoms.  The  onset  of  z.  first  attack  of  asthma  is  abrupt  and 
sudden,  the  succeeding  attacks  being  preceded  hy  prodromes,  which 
the  individual  rapidly  learns  to  appreciate,  to  wit :  coryza,  bronchial 
irritation,  thoracic  constriction,  marked  dyspepsia,  or  a  large  passage 
of  pale,  limpid  urine,  the  "hysterical  urine." 

The  paroxysm  begins,  in  the  majority  of  cases,  in  the  early  morn- 
ing hours  or  during  the  afternoon,  with  a  feeling  of  anguish  and  con- 
striction in  the  chest  and  an  i^ttense  desire  for  air.  The  breathing  is 
accompanied  with  loud  wheezing,  the  face  is  flushed,  at  times  even 


228  PRACTICE   OF   MEDICINE. 

cyanosed,  and  bathed  in  perspiration,  the  eyes  stare,  the  eyeballs  pro- 
trude, and  the  muscles  of  the  neck  become  prominent  as  they  aid  in 
the  effort  for  air.  The  dyspncea  soon  becomes  so  severe  that  the 
inspiration  is  but  a  gasp,  the  lips  are  pallid,  cyanosis  deepens,  and  the 
patient  feels  as  if  death  were  impending. 

After  some  minutes  or  hours  the  respiration  becomes  easier, 
more  air  enters  the  lungs,  the  cyanosis  disappears,  and  gradually 
the  paroxysm  ceases,  the  patient  feeling  exhausted  and  the  chest 
fatigued. 

During  the  paroxysms  there  is  a  short,  dry  cough,  becoming  looser 
as  the  attack  subsides,  the  expectoration  either  consisting  of  white 
pellets  of  mucus,  at  times  streaked  with  blood,  or  profuse  watery 
mucus. 

The  duration  of  an  attack  varies  from  three  to  ten  hours.  Instead 
of  single  paroxysms,  slight  remissions  may  occur  at  intervals  of  one, 
two  or  three  hours,  to  be  followed  by  exacerbations  lasting  from  four 
to  six  hours,  continuing  for  a  week  or  two,  preventing  the  patient 
lying  down  or  taking  food. 

Percussion.  During  the  paroxysm,  hyper-resonance  over  both 
lungs,  termed  vesiculo-tyuipanitic ,  the  "  bandbox  tone  "  of  Bamberger. 

Auscultation.  First  stage  feeble  or  absoit  vesicular  murmur, 
with  prolonged  expiration  associated  with  loud  wheezing,  whistling, 
sibilant  and  sonorous  rales  ;  as  the  paroxysm  subsides  the  vesicular 
breathing  becomes  more  apparent  and  is  associated  with  moist  rales. 

Prognosis.  In  itself  asthma  is  not  fatal  to  life  ;  but  if  the  parox- 
ysms are  frequently  repeated  there  results  either  emphysema,  cardiac 
dilatation,  with  subsequent  dropsy,  or  even  cerebral  hemorrhage. 

Attacks  of  asthma  frequently  occur  as  a  complication  in  emphy- 
sema, chronic  bronchitis  and  valvular  diseases  of  the  heart. 

Treatment.  There  are  two  indications,  to  wit :  the  relief  of  the 
paroxy^^m,  and  to  prevent  its  recurrence. 

To  reliei)e  the  paroxysm,  no  medication  is  so  effective  as  the  hypo- 
dermic injection  of  morphince  sulph.,  gr.  y^  to  }( ,  combined  with 
atropine?  sulph.,  gr.  y^^.  Chloral,  gr.  x,  repeated,  where  no  heart 
complication  exists,  is  often  effective ;  drinking  strong,  hot  black 
coffee  is  often  serviceable ;  chloroformum,  cether  or  amyl  nitris 
inhalations  have  been  recommended  ;  also  nauseant  expectorants,  to 
wit:  lobelia,  ipecac,  scilla,  or  ext.  grindelia fid.,  gtt.  xx,  repeated 
every  two  or  three  hours. 


DISEASES   OF  THE   BRONCHIAL  TUBES.  229 

Dr.  Pepper  speaks  highly  of  the  following  for  the  paroxysm  : — 

R  .     Ammonii  bromidi, 5  'J  9  ij 

Ammonii  muriat., 3'^^^ 

Tinct.  lobelice, ^,^iij 

Spts.  Ktheris  comp., f5j 

Syr.  acacije  q.  s., ,    .  f^iv.  M. 

.SiG. — Dessertspoonful  in  water  every  hour  or  iwo. 

A  combination  that  often  affords  decided  relief  is — 

Be.      Chloral, ^viij 

Ammonii  chloridi, ^iij 

Morphinge  muriat., gi"-  i'j 

Antimonii  et  potassii  tartras, gr.  iiss 

Ext.  grindelise  robust,  fluid,, f^j 

Ex.  glycyrrh., 3  ij 

Syr.  aurantiicort.,     ....  ad ^iv.  M. 

SiG. — One  teaspoonful  in  sweetened  water  every  three  or  four  hours. 
(Davis.) 

Another  remedy  that  at  times  is  successful  is  syrupus  hydriodic. 
acidum,  n^xv-xxx  every  three  or  four  hours. 

Inhalations  of  the  fumes  of  belladonna,  stramonium,  nitre-paper, 
chloroform,  ethyl  bromidum,  or  the  use  of  various  pastilles  or  cigar- 
ettes, are  of  immense  benefit  in  many  cases.  A  twenty  per  cent, 
solution  of  menthol  as  an  inhalation  has  been  successful  in  some 
cases. 

Paroxysms  of  asthma  are  said  to  be  relieved  by  rectal  injections  of 
sulphuretted  hydrogen  after  the  manner  suggested  by  Bergeon  of  Paris. 

If  an  attack  is  impenditig  it  may  often  be  aborted  by  drinking 
freely  of  strong  black  coffee,  or  by  full  doses  of  the  bromides. 

To  prevent  recurrence  of  the  paroxysms,  the  general  health  must 
be  strictly  watched,  any  of  the  complications  or  causes  of  the  attack 
attended  to,  systematic  exercise,  bathing,  regulated  diet,  and  change 
of  climate  when  possible. 

Internally,  good  results  are  sometimes  attained  by  a  long  course  of 
belladonna,  arsenictim  ox  potassii  iodidum. 

HAY  ASTHMA. 

Synonyms.     Hay  fever ;  autumnal  catarrh  ;  rose  fever. 
Definition,     An  acute  catarrhal   inflammation  of  the  upper  air 
passages,  extending  to  the  bronchial  tubes,  associated  with  spasmodic 


230  PRACTICE   OF   MEDICINE. 

contraction  of  their  muscular  layer;  characterized  by  coryza,  croupy 
or  wheezy  cough  and  difficult  respiration. 

Causes.     An  affection  of  the  nervous  system  ;  often  hereditary. 

Persons  in  whom  the  predisposition  exists  have  attacks  excited  by 
the  inhalation  of  the  pollen  of  grasses,  rye,  corn,  wheat  or  roses. 

Pathological  Anatomy.  Hypertrophy  of  the  inferior  and 
middle  turbinated  bones ;  a  peculiar  hypersesthesia  of  the  mucous 
membrane  covering  the  inferior  and  middle  turbinated  bones,  the 
middle  meatus,  the  floor  of  the  nose  and  that  part  of  the  septum 
below  the  limit  of  the  olfactory  membrane  are  frequently  associated 
with  the  disease. 

Symptoms.  Begins  by  severe  coryza,  with  sneezing,  a  clear, 
watery,  nasal  discharge,  congested  eyes  and  Eustachian  tubes,  rapidly 
extending  to  the  larynx  and  bronchial  tubes,  when  occur  a  hoarse , 
crouPy  and  wheezing  cough,  and  difficulty  of  breathing.  The  dyspnoea 
occurs  in  paroxysms,  which  are  often  as  severe  as  those  occurring 
during  a  regular  asthmatic  attack. 

The  paroxysms  remit  after  a  few  days,  returning  again  for  several 
days  or  weeks,  and  again  remitting,  the  bronchial  catarrh  persisting 
for  a  month  or  more. 

The  constitutional  symptoms  are  mild,  unless  complications  occur. 

Complications.  The  affection  may  extend  to  the  finer  bronchial 
tubes  (capillary  bronchitis)  ;  congestion  or  oedema  of  the  lungs  and 
pneumonia  are  not  infrequent. 

Duration.  Unless  a  change  of  climate  is  resorted  to,  paroxysms 
of  hay  fever  continue  more  or  less  severe  for  six,  eight  or  ten  weeks 
of  the  year,  each  year  the  paroxysms  growing  more  severe. 

Prognosis.  The  affection  never  proves  fatal  in  itself,  but  one  or 
more  of  the  following  sequelce  may  result,  to  wit :  Asthma,  chronic 
bronchitis,  or  loss  of  the  special  sense  of  hearing  or  smelling. 

Treatment.  No  specific,  unless  the  hypertrophy  of  the  turbin- 
ated bones  be  a  constant  phenomena,  when  their  removal  by  the 
galvano-cautery  would  at  once  produce  a  cure. 

An  attack  of  hay  asthma  is  often  prevented  by  a  change  of  climate 
during  the  season  of  the  year  when  the  attacks  are  most  common, 
to  wit :  the  early  autumn.  Any  of  the  following  locations  may  be 
selected,  White  Mountains,  Catskills,  Adirondacks,  Rocky  Mountains, 
or  a  sea  voyage. 

Attacks    are    sometimes    aborted    and    always    relieved   by    the 


DISEASES   OF  THE   BRONCHIAL  TUBES.  231 

application  to  the  nares  of  tablets  of  cocaine  hydrochlorate,  gr.  ^ 
every  hour. 

Success  has  followed  the  use  of  quinina,  gr.  v,  three  times  a  day, 
beginning  one  month  before  the  expected  paroxysm.  After  the  attack 
has  fairly  begun,  potassii  iodidum,  gr.  xv,  three  times  a  day,  seems 
to  modify  somewhat  the  severity  of  the  paroxysms  ;  or  the  following 
powder,  by  insufflation  : — 

R.     Bismuth,  subnit., ^ij 

Acid,  tannic  , ^j 

lodoformi, gr.  xv.  M. 

SiG. — Every  three  or  four  hours. 

Prof.  Bartholow  "has  seen  several  cases  benefited  greatly  "  by  a 
solution  of  quinina  applied  to  the  nares,  as  suggested  by  Helmholtz  ; 
"  but  to  achieve  success  the  application  must  be  thorough  and  timely." 

The  following  applied  thoroughly  to  the  nostrils  has  a  high  repute  : — 

R.     Menthol., 5J 

Cerat.  simpl., 5ij 

01.  amygd.  dulcis, .1  ^ss 

Zinci  oxidi  purse,    , ^j 

Acid,  carbolici, .5ss.  M. 

SiG. — Apply  every  few  hours. 

Cases  accompanied  by  a  profuse  watery  discharge  have  this  symp- 
tom at  least  modified  by  minute  doses  of  atrophincs  sulphas,  with 
morphincz  sulphas,  every  three  or  four  hours. 

A  long  course  of  arsenicum  in  minute  doses  sometimes  removes 
the  susceptibility  to  the  disease. 


WHOOPING  COUGH. 

Synonyms.     Hooping  cough  ;  pertussis. 

Definition.  A  convulsive,  paroxysmal  cough,  consisting  of  a 
number  of  forcible  expirations,  followed  by  a  series  of  deep,  loud, 
sonorous  inspirations  (the  whoop),  repeated  several  times  during  each 
paroxysm,  and  associated  with  catarrh  of  the  bronchial  tubes. 

Causes.  Chiefly  a  disease  of  childhood,  one  attack  generally 
removing  the  susceptibility ;  contagious  ;  the  result  of  an  unknown 
poison,  perhaps  atmospheric,  affecting  the  nervous  system. 

Pathology.     The   changes,   if    any,   occurring  in   the   nervous 


232  PRACTICE   OF    MEDICINE. 

system  are  unknown.  It  is  said  that  "irritation  of  the  internal  branch 
of  the  superior  laryngeal  nerve  produces  relaxation  of  the  diaphragm. 
spasm  of  the  glottis  and  a  convulsive  expiration,  the  series  of  phe- 
nomena present  in  a  paroxysm  of  asthma." 

Hypercemia  of  the  mucous  membrane  of  the  nares,  pharynx, 
lar)'nx  and  bronchial  tubes,  with  diminished  secretion^  followed  by 
an  increased  secretion  of  a  transparent  mucus,  afterward  becoming 
purulent,  the  mucous  membrane  pale  and  anaemic. 

Symptoms.  Divided  into  three  stages,  to  wit :  catarrhal,  spas- 
modic and  terminal. 

Catarrhal  stage  originates  as  an  ordinary  naso-laryngo-bronchial 
catarrh  with  a  loose  cough.     Duration  one  or  two  weeks. 

Spastnodic  stage.  The  cough  becomes  paroxysmal,  consisting  of 
a  succession  of  short,  rapid,  expiratory  efforts,  the  face  becoming 
red,  the  eyes  swoUen  and  protruding,  the  body  bending  forward, 
and  when  these  expiratory  efforts  have  exhausted  the  breath,  they 
are  followed  by  a  deep,  loud,  crowing  inspiration — the  whoop  ;  each 
paroxysm  being  composed  of  three  such  spells,  the  last  one  followed 
by  the  expectoration  of  a  small  amount  of  totigh,  viscid  7nucus. 

The  attacks  of  cough  may  be  so  severe  as  to  cause  vomiting,  and  if 
the  vomiting  occur  shortly  after  food  has  been  taken,  the  nutrition  of 
the  patient  will  suffer.  VxoiMSO.  epistaxis  is  not  infrequent.  Duration 
about  four  weeks. 

Terminal  stage.  The  paroxysms  recur  at  longer  intervals,  are  of 
short  duration  and  less  intensity,  the  catarrhal  symptoms  being 
more  marked,  the  expectoration  freer.  Duration,  one  or  two  weeks, 
often  followed  by  the  "  cough  of  habit." 

Complications.  Congestion  of  the  lungs,  capillary  broncliitis, 
pneumonia  and  emphysema,  or,  rarely,  convulsions,  hydrocephalus, 
or  apoplexy. 

Diagnosis.  During  the  catarrhal  stage,  whooping  cough  cannot 
be  distinguished  from  a  common  cold,  but  on  the  advent  of  the 
characteristic  whoop  the  diagnosis  is  evident. 

Prognosis.  Depends  upon  the  age  and  strength  of  the  patient, 
the  severity  of  the  paroxysms,  and  the  presence  or  absence  of  com- 
plications. Ordinary  cases,  favorable.  Moderately  severe  attacks 
during  infancy  are  followed  by  cerebral  symptoms,  while  attacks 
occurring  in  adults  are  followed  by  chest  symptoms. 

Treatment.     No   specific.     A    self-limited    disease.      Remedies 


DISEASES   OF  THE   BRONCHIAL   TUBES.  233 

will   not  cure   the   disease,   but   often    modify   the   severity   of   the 
symptoms. 

Prof.  Da  Costa  prefers  quinincB  sulphas,  in  full  doses,  or  chloral  in 
good-sized  doses,  often  advantageously  combined  with  the  bromides, 
and  the  use  of  a  spray  of  sodii  bromidum  (gr.  xx,  and  aquse,  f^j)  to 
which  may  be  added  extractum  belladottncE  Jltddum,  n\^ij.  A  remedy 
of  great  utility  is  ajnmonii  bromidum.  I  have  seen  excellent  results 
from  antipyriiie  in  doses  of  gr.  j-ij  every  three  hours ;  if  added  to 
some  expectorant  mixture  it  seemed  to  act  better.  The  paroxysms  are 
lessened  in  severity  by  the  following : — 

R .     Codeinge  sulph., gr.  j 

Acid,  carbolic, lU-'^^J 

Syr.  simplicis, f.^ss 

Glycerini, f  5j 

Syr.  limonis, fsss.  M. 

SiG. — One  teaspoonful  every  two  or  three  hours. 

Belladonna  may  be  added  to  any  of  the  remedies  named  with 
advantage. 

The  use  of  cocaine  lozenges  modifies  the  paroxysms  in  some  cases. 

Dr.  Keating  reports  "  remarkable  improvement  in  four  cases  of 
whooping  cough  by  the  use,  four  or  six  times  daily,  of  a  spray  com- 
posed of" — 

R.     Ammonii  bromid., 

Potassii  bromid., aa ^j 

Tinct.  belladcnnae, f,:^j 

Glycerini, f ^^  j 

Aquse  rosse, q.  s.  ad ^S^^'* 

The  diet  of  the  patient  must  be  regulated,  the  clothing  to  be  warm 
but  not  too  heavy,  and  the  patient  kept  in  the  open  air  as  long  as 
possible. 

EMPHYSEMA. 

Synonym.     Vesicular  emphysema. 

Definition.  Dilatation  of,  or  increase  in  the  size  and  capacity  of, 
the  air  vesicles,  characterized  by  enlargement  of  the  chest,  difficulty 
of  breathing,  especially  on  exertion,  and  associated  sooner  or  later 
with  dilatation  of  the  heart. 

Causes.     The  predisposing  cause  of  emphysema  is  a  hereditary 


234  PRACTICE   OF   MEDICINE. 

nutritive  derangement  of  the  lung  structure,  often  associated  with  a 
rigid  enlargement  of  the  thorax. 

The  exciting  cause  is  the  result  either  of  a  too  forcible  and  long 
continued  inspiration — the  theory  of  inspiration — or  the  excessive 
mechanical  distention  of  the  vesicular  walls  by  forced  expiration — 
the  theory  of  expiration. 

What  is  known  as  vicarious  emphysema  is  a  distention  of  the  air 
cell  of  the  healthy  portions  of  the  lung,  some  other  part  being  the 
seat  of  consolidation. 

Interlobular  emphysema  is  the  presence  of  air  in  the  spaces  between 
the  lobules  of  the  lungs  underneath  the  pulmonary  pleura. 

Pathological  Anatomy.  The  situation  of  vesicular  emphysema 
is,  in  the  majority  of  cases,  the  stiperior  portions  of  the  chest,  and  is 
more  marked  on  the  left  side  than  on  the  right. 

An  emphysematous  lung  feels  remarkably  soft  to  the  touch,  and 
upon  cutting,  a  dull,  creaking  sound  is  barely  perceptible.  It  is  of  a 
pale  red  color,  the  vesicular  walls  are  thinner  and  lighter,  the  vesicles 
are  greatly  enlarged,  sometimes  to  the  size  of  a  pea  or  bean,  and  have 
an  irregular  shape,  and  traversing  most  of  these  large  cysts  (dilated 
vesicles)  a  few  delicate  bands,  the  remains  of  the  lacerated  inter- 
alveolar  septa,  are  visible.  With  the  destruction  of  the  septa  many  of 
the  capillaries  are  destroyed,  whereby  the  emphysematous  tissue  is 
remarkably  bloodless  and  dry. 

In  consequence  of  the  destruction  of  so  many  of  the  capillaries,  the 
obstruction  to  the  pulmonary  circulation  becomes  so  great  that  the 
pulmonary  artery  and  right  cavities  of  the  heart  are  greatly  dis- 
tended ;  finally,  the  muscular  tissue  of  the  heart  undergoes  granular, 
followed  by  fatty,  degeneration.  This  distention  of  the  veins  results 
in  a  general  venous  stasis,  to  wit :  nutmeg  liver,  congested  kidneys, 
and  gastro-intestinal  catarrh. 

Symptoms.  The  chief  symptoms  of  vesicular  emphysema  are 
difficulty  of  breathing,  greatly  aggravated  on  exertion,  more  or  less 
cough,  the  result  of  an  attending  bronchitis,  and  the  various  symp- 
toms resulting  from  dilatation  of  the  heart.  The  distress  of  the  patient 
is  often  increased  by  paroxysms  of  asthma. 

Inspection.  The  shoulders  are  rounded,  the  intercostal  spaces 
widened,  the  vertical  diameter  elongated,  with  circumscribed  promi- 
nences between  the  clavicles  and  nipples,  often  increased  by  the 


DISEASES  OF  THE   BRONCHIAL  TUBES.  235 

act  of  coughing — the  peculiar  "barrel-shaped  "  chest  characteristic  of 
this  disease. 

The  character  of  the  respiratory  movements  is  marked,  there  being 
but  slight  movement  observed  on  forcible  respiration,  the  chest  hav- 
ing the  constant  appearance  of  a  full  inspiration. 

Palpation.  The  vocal  fremitus  is  diminished,  and  the  cardiac 
impulse  depressed  and  nearer  to  the  sternum. 

Percussion.  The  resonance  is  increased  (hyper-resonant)  over 
all  the  emphysematous  portions,  and  if  the  whole  lung  be  involved, 
extends  to  the  seventh  or  eighth  rib  anteriorly,  and  to  the  twelfth  rib 
posteriorly.  The  hepatic  dullness  may  not  begin  until  the  inferior 
margin  of  the  ribs  is  reached  ;  the  cardiac  dullness  is  lessened,  on 
account  of  the  emphysematous  lung  nearly  covering  the  heart. 

Auscultation.  The  vesicular  murmur  is  weakened,  and  in  pro- 
nounced cases  almost  absent.  If  bronchitis  be  present,  the  inspiratory 
sound  may  be  rough  or  sibilant  in  character,  but  its  duration  is  always 
shortened.  Expiration  is  always  prolonged,  and  if  bronchitis  be 
present,  may  be  associated  with  more  or  less  pronounced  moist  or 
bubblitig  rales. 

Th.Q  first  sound  of  the.  h.Q3xt  IS  lessened  in  intensity  and  duration, 
the  second  sound  being  sharply  accentuated. 

Diagnosis.  Bronchitis  is  distinguished  from  emphysema  by  the 
absence  of  dyspnoea,  hyper-resonance  of  the  chest,  changes  in  its 
shape,  size  and  movements,  and  the  disturbance  of  the  circulation. 

Spasmodic  asthma  by  the  paroxysmal  character  of  the  affection, 
emphysema  being  a  permanent  malady,  with  attacks  of  asthma. 

Cardiac  diseases  due  to  other  causes  than  emphysema  do  not  have 
the  characteristic  physical  signs  of  that  affection. 

Prognosis.  Vesicular  emphysema  is  essentially  a  chronic  dis- 
ease. In  itself  it  rarely  proves  fatal,  but  if  aggravated,  from  any 
cause,  or  if  associated  with  severe  or  prolonged  asthmatic  paroxysms 
the  cardiac  changes  are  hastened,  general  dropsy  supervenes,  death 
occurring  from  exhaustion,  or,  more  commonly,  as  the  result  of  inter- 
current attacks  of  pneumonia. 

Treatment.  It  being  impossible  to  restore  the  altered  lung  struc- 
ture, the  indications  for  treatment  are  to  relieve  the  symptoms  and  to 
endeavor  to  prevent  its  further  progress. 

For   the   relief  of  the   asthmatic    paroxysms,   morphince  sulphas 


236  PRACTICE   OF   MEDICINE. 

combined  with  atrophicE  sulphas  may  be  used  hypodermically,  or  ext. 
quebracho  fld.,  oss-j,  every  hour  until  relief,  or  large  doses  oi potassii 
bromidiim ,  frequently  repeated. 

For  attacks  of  bronchial  catarrh  use — 

R .     Ammonii  chloridi, ,:^  ij 

Spts.  frument., ^Tt}^ 

Glycerini, f  t  j 

Syr.  prun.  virg., ad f^iv.  M. 

SiG. — Half-tablespoonful  every  few  hours. 

To  prevent  the  progress  of  the  affection,  remove  the  bronchial 
catarrh,  relieve  the  difficulty  of  breathing,  and  strengthen  the  cardiac 
action,  no  one  combination  seems  comparable  with  the  following: — 

B  .      Potassii  iodidi, gr.  v 

Strychninae  sulph., S^-  iV 

Liq.  potassii    arsenit., TT^v 

Aq.  lauro  cerasi ^7i\-  M* 

SiG. — Four  times  a  day. 

But  of  all  means  hitherto  proposed  for  the  relief  of  emphysema, 
nothing  has  approached  the  inhalation  of  compressed  air,  by  means 
of  the  apparatus  of  Waldenberg. 

The  dropsy  arising  from  failure  of  the  heart  to  compensate  for  the 
circulatory  derangement  in  the  lungs,  may  be  relieved  for  a  time  by 
the  use  of  digitalis,  or,  if  this  fails,  scilla  combined  with  hydragogue 
cathartics. 

HEMOPTYSIS. 

Synonyms.  Bronchial  hemorrhage  ;  broncho-pulmonary  hemor- 
rhage ;  bronchorrhagia. 

Definition.  The  expectoration  of  pure  or  unmixed  blood,  usually 
of  a  bright  red  color,  following  the  act  of  coughing. 

Causes.  In  the  majority  of  cases,  the  result  of /«(5<?rr«/(«r  disposi- 
tion in  the  walls  of  the  minute  bronchial  arteries  ;  excessive  cardiac 
action  ;  bronchial  congestion  ;  excessive  bodily  exertion,  straining, 
lifting  or  running  ;  a  symptom  of  hcemophilia  ("bleeders'  disease"). 

Pathological  Anatomy.  Haemoptysis  rarely  causes  death  in 
itself,  so  that  few  opportunities  for  observing  post-mortem  appear- 
ances are  obtained,  and  when  they  do  occur,  the  location  of  the 
hemorrhage  is  seldom  found. 


DISEASES   OF  THE   BRONCHIAL  TUBES.  237 

The  air  passages  are  more  or  less  filled  with  clotted  blood,  the 
mucous  membrane  is  swollen,  and  of  a  dark  red  color,  rarely,  pale 
and  bloodless.  The  air  cells  contain  blood  clots,  or  are  distended 
with  air,  the  bronchi  being  filled  with  clots  preventing  its  escape. 
Unless  the  clots  are  rapidly  removed  by  expectoration  or  absorption, 
a  secondary  inflammation  originates  around  about  them. 

Symptoras.  "  Spitting  of  blood  "  occurs  suddenly ;  rarely,  it  is  pre- 
ceded by  epistaxis,  cardiac  palpitation  and  some  difficulty  of  breathing. 

It  begins  with  a  sensation  of  warmth  under  the  sternum,  tickling 
in  the  throat,  a  sweetish  taste  in  the  mouth,  which,  upon  attempting  to 
remove  by  the  act  of  coughing,  a  wan?i,  saltish,  bright  red,  frothy 
liquid  gushes  from  the  mouth  and  nose.  The  quantity  of  blood 
raised  varies  from  an  ounce  to  a  pint.  The  appearance  of  the  blood 
depresses  the  individual,  he  becoming /a/^,  trejuulous,  oil&n  fainting. 

The  attack  may  subside  within  half  an  hour  to  several  hours, 
returning  for  several  days,  in  the  meantime  the  expectoration  being 
either  bloody  or  streaked  with  blood. 

A  slight  febrile  reaction,  with  chest  pains,  supervenes  upon  the 
hemorrhage,  the  result  of  the  inflammation  at  the  site  of  the  bleeding, 
which  soon  subsides,  except  where  blood  clots  develop  a  secondary 
pneumonia,  which  may  undergo  the  cheesy  metamorphosis. 

Auscultation.  Coarse,  bubblijtg  rales  are  discerned  in  circum- 
scribed portions  of  the  chest. 

Diagnosis.  From  epistaxis,  or  hemorrhage  from  the  posterior 
nares,  it  is  distinguished  by  the  absence  of  air  bubbles  and  an  inspec- 
tion of  the  fauces  and  the  nasal  cavities. 

HcBmatemesis,  or  hemorrhage  from  the  stomach,  differs  from 
haemoptysis  in  the  blood  being  vomited  instead  of  expectorated,  of  a 
dark  color,  clotted,  mixed  with  the  acid  contents  of  the  stomach,  fol- 
lowed with  black,  tar-like  stools,  and  the  absence  of  rales  in  the  chest. 

Exceptions  to  the  above  occur  when  the  blood  from  the  lungs  is 
first  swallowed  and  afterwards  raised  by  vomiting,  or  when  the  hem- 
orrhage in  the  stomach  is  caused  by  the  erosion  of  a  large  artery,  the 
result  of  ulcer  of  the  stomach  ;  in  these  cases,  however,  the  raising  of 
blood  is  preceded  by  epigastric  pain  and  the  blood  is  not  frothy. 

Prognosis.  Haemoptysis  in  itself  rarely  terminates  fatally,  al- 
though causing  much  depression  ;  the  patient  rapidly  recovers,  unless 
secondary  pneumonia  results.  In  nine  cases  out  of  ten  it  is  the  prog- 
nostic sign  of  phthisis. 


238  PRACTICE   OF   MEDICINE. 

Treatment.  Perfect  rest  in  bed,  the  head  and  shoulders  elevated, 
and  perfect  quiet,  the  diet  to  be  bland,  the  drinks  cool,  the  patient 
slowly  swallowing  small  particles  of  ice.  C-'jnmon  salt,  slowly  dis- 
solved in  the  mouth,  is  a  popular  remedy,  and  if  of  no  real  benefit, 
serves  to  occupy  the  attention  of  the  patient  and  friends  until  medical 
advice  is  obtained. 

The  hypodermic  injection  of  ergotin,  gr.  x-xxx,  or  the  internal 
administration  of  extractum  ergotcz  Jluidum,  5ss-j,  are  valuable,  or  : — 

R.     Acid,  gallic, gr- xv 

Acid,  sulph.  dil., TT^x 

Aqua  cinnamon,      3  '^'  ^' 

Repeated  every  fifteen  or  twenty  minutes. 

Or  tinctura  matico,  5j,  or  extractum  hajnamelis  fld.,  n\,xx-3j,  ahcme7i, 
gr.  XX,  or  acidum  galliciim,  gr.  v-x,  frequently  repeated. 

If  the  hemorrhage  causes  great  nervous  excitement,  or  depression, 
opium,  either  hypodermically  or  internally,  to  quiet  the  patient,  is 
indicated. 

Inhalations,  by  msans  of  the  steam  atomizer,  of  either  MonseVs 
solution  or  tinctura  ferri  chloridum,  are  recommended  when  the 
above  means  fail. 

Prof.  DaCosta  recommends,  for  frequent  small  hemorrhages,  con- 
tinuing day  after  day,  cupri  sulphas  (gr.  y\),  ext.  opii  (gr.  j^).  P«  ^^-  ^i. 


DISEASES  OF  THE  LUNGS. 


CONGESTION  OF  THE  LUNGS. 

Synonym.     Hyperaemia  of  the  lungs. 

Definition.  An  increase  in,  or  abnormal  fullness  of,  the  capil- 
laries of  the  air  cells ;  active  congestion  when  the  result  of  an  accel- 
erated circulation  ;  passive  congestion  when  caused  by  an  impeded 
outflow  from  the  capillaries. 

Causes.  Active.  Increased  cardiac  action  ;  over  exertion  ;  alco- 
holic excesses  ;  mental  excitement ;  inhalation  of  cold  or  hot  air. 

Passive.  Obstruction  to  the  return  circulation.  Dilated  heart  ; 
valvular  diseases;  low  fevers  (hypostatic  congestion);  Bright's 
diseases. 


DISEASES   OF   THE   LUNGS.  239 

Patholog'y.  The  hypersemic  lung  has  a  bloated,  dark  red 
appearance,  its  vessels  are  distended  to  the  uttermost,  the  tissues 
succulent  and  relaxed,  blood  flowing  freely  over  the  cut  surface  ;  a 
bloody,  frothy  liquid  is  present  in  the  bronchi,  and  the  alveolar  walls 
are  so  much  swollen  that  the  condensed  lung  shows  scarcely  any 
indication  of  its  cellular  structure,  resembling  the  tissue  of  the  spleen 
{sple7iiJicatio7i) . 

Symptoms.  Active.  Rapidly  developing  thoracic  distress  and 
difficulty  of  breathing,  flushed  face,  stroftg,  full  pulse,  throbbing  caro- 
tids, cardiac  palpitatio7i  and  congested  eyes,  with  a  short,  dry  cough, 
followed  by  scanty,  frothy  expectoration  slightly  streaked  with  blood. 

Passive.  Developed  slowly,  with  difficulty  of  breathing,  blueness 
of  the  surface,  almost  continuous  hacking  cough,  followed  by  scanty 
blood-streaked  expectoration. 

Percussion.  The  resonance  of  the  lungs  slightly  diminished,  the 
quality  of  the  sound  being  somewhat  tympanitic. 

Auscultation,  The  vesicular  murmur  is  diminished,  and  accom- 
panied with  sub-crepitant  rales. 

Duration.  Active.  Usually  from  three  to  five  days,  terminating 
either  by  resolution,  hemorrhage,  or,  rarely,  pneumonia.  The  onset 
may  be  so  severe  and  sudden  that  death  rapidly  supervenes. 

Passive.  Developed  slowly  and  subject  to  great  variations,  depend- 
ing upon  the  cause. 

Diagnosis.  Active  congestion  of  the  lungs  cannot  be  distinguished 
from  the  stage  of  engorgement  of  a  true  pneumonia,  in  the  majority 
of  cases. 

Prognosis.  An  acute  congestion  of  the  lungs  may  prove  fatal 
within  a  few  hours,  but  under  prompt  treatment  it  generally  termi- 
nates favorably. 

The  passive  form  is  controlled  entirely  by  the  cause. 

Treatment.  Active.  In  the  strong  and  vigorous  wet  cups  to  the 
chest,  or,  if  the  symptoms  are  pronounced,  a  general  venesection. 
Internally,  tinctura  acoftiti,  gtt.  j-ij  every  half  hour  or  hour,  as  indi- 
cated, -with  free  catharsis  with  saline  purgatives. 

Passive.  Dry  or  wet  cups  over  the  chest,  hydragogue  cathartics, 
and  the  internal  administration  of  digitalis  ;  if  much  depression  of 
the  vital  powers,  stimulants  such  as  spiritus  vini gallici  and  ammonii 
carbonas  are  indicated. 


240  PRACTICE   OF   MEDICINE. 

OEDEMA  OF  THE  LUNGS. 

Definition.  An  effusion  of  serum  upon  the  free  surface  of  the 
lung,  to  wit :  in  the  puhnonary  vesicles ;  characterized  by  dyspnoea, 
cough,  and  frothy,  blood-streaked  expectoration. 

Causes.  Result  of  cardiac  diseases ;  Bright's  disease ;  over- 
exertion ;  alcoholic  excesses ;  mental  excitement ;  inhalation  of  cold 
or  hot  air. 

Pathological  Anatomy.  The  lung  tissue  is  swollen,  and  does 
not  collapse  when  the  chest  is  open.  The  elasticity  of  the  tissue 
has  disappeared,  and  it  pits  upon  pressure. 

If  following  congestion  of  the  lungs,  the  color  is  red  ;  if  a  symptom 
of  a  general  dropsy,  its  color  is  pale. 

On  cutting  into  the  oedematous  spots  an  enormous  quantity  of 
liquid,  sometimes  clear,  at  other  times  of  a  red  color,  mixed  more  or 
less  with  blood,  flows  over  the  cut  surface.  The  liquid  is  filled  with 
bubbles,  is  frothy,  from  being  copiously  mixed  with  air,  providing  the  air 
cells  have  not  been  entirely  filled  with  serum,  thereby  excluding  the  air. 

Symptoms.  Following  a  more  or  less  rapidly  developing  hyper- 
aemia  of  the  lungs  are  great  oppression  of  and  extreme  rapidity  i?i 
breathing,  with  a  strong  sense  of  oppressioti,  great  anxiety,  rapid  and 
tumultuous  cardiac  action,  throbbing  carotids  and  temporals,  fullness 
of  the  head  and  headache,  flushed  face  and  congested  eyes,  with  a 
constant  short  cough,  and  the  expectoration  of  a  tough,  frothy  mucus, 
streaked  with  blood. 

If  the  effusion  into  the  air  cells  be  sufficient  to  prevent  the  entrance 
of  air,  symptoms  of  cyanosis  rapidly  supervene,  the  pulse  becoming 
feeble,  the  surface  cold,  the  breathing  shallow  and  hurried,  the  cough 
suppressed,  stupor  replacing  the  restlessness,  soon  deepening  into  coma. 

Percussion.     Slightly  impaired  or  vesiculo-tympanitic. 

Auscultation.  The  vesicular  murmur  is  supplanted  by  sub- 
crepitant  and  bubbling  rales. 

Diagnosis.  Pneumonia  in  the  earlier  stages  is  the  only  condition 
likely  to  be  confounded  with  oedema  of  the  lungs,  and  the  subsequent 
course  of  the  two  maladies  soon  determines  the  diagnosis. 

Prognosis.  (Edema  of  the  lungs  is  always  a  serious  malady,  and 
frequently,  unless  promptly  relieved,  terminates  fatally. 

Treatment.  If  the  oedema  be  of  an  active  kind,  prompt  ^/.9^^- 
letting,  either  by  venesection  or  wet  cups  to  the  chest,  is  indicated. 


DISEASES   OF  THE   LUNGS.  241 

The  internal  administration  of  tinctura  aconiti,  gtt,  j-ij,  repeated 
every  fifteen  minutes,  until  the  cardiac  action  is  markedly  reduced, 
after  which  every  hour  or  two,  with  the  use  of  the  preparations  of 
ammonimn,  either  the  carbonas  or  iodidum,  to  liquefy  the  effusion, 
produce  marked  relief. 

The  above  means  may  be  aided  by  counter-irritation  to  the  chest, 
hot  mustard  foot  baths,  active  saline  purgatives,  and  diuretics. 


CROUPOUS   PNEUMONIA. 

Synonyms.  Lobar  pneumonia ;  pneumonitis  ;  fibrinous  pneu- 
monia ;  pleuro-pneumonia  ;  lung  fever  ;  winter  fever. 

Definition.  An  acute  croupous  inflammation  involving  the  vesi- 
cular structure  of  the  lungs,  rendering  the  alveoli  impervious  to  air ; 
characterized  by  a  severe  chill,  fever,  pain,  dyspnoea,  cough,  rusty 
sputum  and  great  prostration. 

Causes.  The  question  of  pneumonia  being  a  constitutional  dis- 
ease is  still  sub  judice,  although  the  belief  is  growing,  as  it  presents 
such  a  marked  difference  from  other  inflammations,  in  that  it  is  self- 
limited,  and  terminates  by  crisis.  It  is  most  common  in  winter,  at 
times  occurring  epidemically ,  the  result  of  atmospheric  conditions  ; 
exposure  to  draughts  and  cold  ;  injuries  to  the  chest  walls  ;  alcoholic 
excesses  ;  gout  or  rheumatism. 

Pathological  Anatomy.  The  inflammatory  changes  most 
commonly  affect  the  lower  right  lobe,  rarely  the  upper  lobe,  very 
rarely  corresponding  lobes  in  both  lungs. 

The  changes  are,  I.  Hypercsmia  (engorgement) ;  II.  Exudation 
(red  hepatization)  ;  III.  Resolution  (gray  hepatization)  ;  or  it  may 
undergo  purulent  transformation  or  the  development  of  abscesses 
(yellow  hepatization), 

I.  Stage  of  hypercEmia  or  engorgement  consists  in  the  vessels  of 
the  alveoli  being  distended  to  their  utmost,  encroaching  upon  the 
cavity  of  the  air  vesicle ;  the  lung  has  a  reddish-brown  color,  is  heavier, 
sinking  somewhat  lower  in  water  than  a  normal  lung,  and  having  a 
slight  exudation  upon  the  vesicular  surface.  The  same  changes  are 
perceived  in  the  adjacent  bronchioles. 

II.  Stage  of  exudation  consists  in  the  exudation  of  a  viscid,  fibrin- 
ous fluid,  admixed  with  white  and  red  corpuscles  and  blood,  which 
rapidly  coagulates,  firmly  enclosing  the  corpuscles  and  completely 

20 


242  PRACTICE   OF   MEDICINE. 

filling  the  alveoli.  When  the  exudation  and  coagulation  are  com- 
pleted, the  lung  is  red,  sinks  at  once  when  placed  in  water,  and  its 
elasticity  is  destroyed.  When  cut  into,  the  color,  density  and  granu- 
lar appearance  so  closely  resemble  the  cut  surface  of  a  section  of  the 
liver,  that  Lccnnec  termed  it  red  hcpatisation. 

III.  Resolution,  or  gray  hepatization,  follows  the  above  condition  in 
the  majority  of  cases,  the  coagulated  albuminous  exudation  under- 
going liquefaction  and  absorption,  the  cellular  element  undergoing  a 
fatty  degeneration,  the  greater  part  being  absorbed,  the  remainder 
expelled  during  acts  of  expectoration,  the  alveoli  returning  to  their 
normal  condition,  both  as  to  capacity,  function  and  elasticity. 

If  resolution  be  retarded  and  portions  of  the  coagulated  exudation 
undergo  purulent  tmnsforjnation,  changing  from  a  yellowish  to  a 
greenish-yellow  color  (yellow  hepatization),  pus  cells  are  rapidly 
formed,  the  part  becoming  a  granular,  fatty  mass.  The  portions  of 
the  lung  not  undergoing  this  purulent  transformation  retain  the  red- 
dish color  with  intermixed  yellowish  patches,  the  lung  structure  proper 
remaining  intact.  The  purulent  contents  may  be  ejected  in  part,  the 
remainder  undergoing  fatty  degeneration  and  finally  absorption. 

Abscess  of  the  lung  may  result  from  the  lung  structure  becoming 
involved  in  the  purulent  disintegration.  Abscesses  may  be  solitary 
or  in  great  numbers,  which  by  disintegration  of  intervening  structure 
form  one  or  more  large  abscesses  ;  these  abscesses  either  terminate 
fatally,  or  open  into  the  pleural  cavity,  causing  empyema  and  exhaus- 
tion, or  open  into  the  bronchi  and  are  expectorated,  or  an  interstitial 
pnetwiotiia  is  developed  and  the  abscess  encapsulated  in  a  firm  cica- 
tricial tissue. 

Gangrene  of  the  lungs  may  result  from  blocking  up  of  the  bronchial 
or  pulmonary  arteries  by  coagula,  during  any  stage  of  the  disease. 

The  uninflamed  portions  of  the  lungs  are  hyperaemic  and  their 
functional  activity  is  increased. 

Death  sometimes  results  from  a  general  oedema  of  the  unaffected 
lung,  such  cases  being  often  erroneously  termed  "  double  pneumonia." 

If  inflammation  of  the  pleura  be  associated  with  a  pneumonia,  the 
so-called  pleuro-pneujnonia,  the  changes  in  the  pulmonary  pleura  are 
characteristic.  "An  uneven,  thin,  downy-looking  layer  of  plastic 
exudation  covers  its  surface.  This  plastic  layer  may  conceal  the 
liver-brown  color  of  the  pneumonic  lung.  As  the  third  stage  is 
reached  the  opposing  surfaces  of  the  pleura  may  become  agglutinated. 


DISEASES    OF   THE   LUNGS.  243 

The  pleuritic  changes  follow  very  closely  those  which  occur  within 
the  lung.  The  cells  in  the  pleuritic  exudation  are  mainly  pus.  The 
pleuritic  membrane  is  opaque,  congested  and  ecchymotic.  It  may 
become  so  thick  as  to  give  a  dull  note  on  percussion,  after  resolution 
is  reached." 

Duration  of  stages :  stage  of  congestion,  from  one  to  three  days ; 
stage  of  exudation,  from  three  to  seven  days  ;  stage  of  resolution,  from 
one  to  three  weeks. 

In  severe  cases  or  in  the  very  young,  the  aged  or  the  depressed,  the 
stage  of  red  hepatization  may  be  fully  developed  within  forty-eight 
hours. 

Seat :  The  most  frequent  seat  of  croupous  pneumonia  is  the  lower 
right  lobe  ;  the  next  most  frequent  seat  is  the  lower  left  lobe ;  the 
next,  the  upper  right  lobe,  although  in  children  and  the  aged  this  lobe 
is  affected  equally  as  often  as  the  right  lower  lobe. 

Syraptoms.  Begins  with  a  severe  and  usually  protracted  chill 
(in  children  often  convulsions,  adults,  vomiting),  followed  by  a  rapid 
rise  of  te7nperature^  103°-I04°  F.,  a  strong,  full,  but  rapid  pulse,  soon 
showing  evidences  of  embarrassed  cardiac  action  from  obstructed 
respiratory  circulation,  either  a  dull  or  sharp  pain  near  the  nipple, 
aggravated  by  pressure,  breathing  or  coughing,  shortness  of  breath, 
the  number  of  respirations  increasing  to  40,  50  or  more  per  minute, 
causing  interrupted  speech  ;  cough,  first  short,  ringing  and  harsh, 
soon  followed  by  a  scanty,  frothy  mucus,  soon  becoming  semi-trans- 
parent, viscid  and  tenacious,  about  the  second  day  changing  to  the 
familiar  rusty  sputum,  becoming  more  copious  and  of  a  yellow  color 
as  the  disease  advances  ;  rarely  cases  occur  with  bloody  or  blood- 
streaked  sputum  during  the  continuance  of  the  fever.  There  are 
present  headache,  sleeplessness,  rarely  delirium,  save  in  drunkards, 
epistaxis,  flushed  countenance,  and  especially  over  the  malar  bones  is 
a  well-defined  mahogany  blush ;  gastric  disturbances  and  scanty, 
high-colored  urine,  with  diminished  chlorides,  often  albuminuria. 

From  the  very  onset  of  the  disease  the  prostration  is  of  the  most 
marked  character. 

The  above  symptoms  continue  more  or  less  marked  until  either  the 
fifth,  seventh,  nitith  or  eleventh  day,  when  a  crisis  occurs,  and  within 
twenty-four  hours  convalescence  is  established,  recovery  rapidly  fol- 
lowing. 

Typhoid  pneumonia  is  a  term  applied   to  those  cases  which  are 


244  PRACTICE   OF   MEDICINE. 

accompanied  by  signs  of  extreme  prostration,  delirium,  tremor,  very 
high  temperature  and  profuse  and  prolonged  exudation.  They  may 
also  terminate  by  a  crisis. 

Bilious  pneumo7iia  occurs  in  cases  accompanied  by  congestion  of 
the  liver,  the  result  of  venous  stasis  from  pulmonary  obstruction  or 
from  an  accompanying  acute  catarrhal  Jautidice.  In  malarial  dis- 
tricts pneumonia  and  malaria  are  often  associated,  when  jaundice, 
more  or  less  pronounced,  occurs.  Such  cases  are  termed  inalarial  or 
in  term  it  tent  pneumon  ia . 

If  purulent  infiltration  follow  the  stage  of  red  hepatization,  instead 
of  a  crisis,  symptoms  of  exhaustion  occur,  with  profuse  purulent  ex- 
pectoration, high  temperature,  severe  sweats ;  the  tongue  brown  and 
dry,  sordes  collecting  on  the  teeth,  recovery  slow  and  convalescence 
tedious. 

Pneumonia  occurring  in  persons  of  intemperate  habits  usually 
begins  with  symptoms  closely  resembling  an  attack  of  delirium 
tremens,  cough  and  expectoration,  the  pain  very  slight,  or  even  absent. 

Inspection.  First  stage,  deficient  movement  of  the  affected  side, 
due  to  the  pain. 

Second  stage,  the  healthy  side  rises  normally,  the  affected  side  lag- 
ging behind.  If  both  lower  lobes  are  impervious  to  air,  the  diaphragm 
cannot  descend  and  the  epigastrium  does  not  project  during  inspira- 
tion, the  breathing  being  conducted  by  the  upper  part  of  the  chest 
(superior  costal  repiration). 

Palpation.  First  stage,  the  vocal  fremitus  more  distinct  than 
normal. 

Second  stage,  the  vocal  fremitus  is  markedly  exaggerated,  except  in 
those  rare  instances  of  occlusion  of  the  bronchi  by  secretion. 

The  cardiac  impulse  is  felt  in  the  normal  position. 

Percussion.  First  stage,  the  percussion  noted  is  slightly  impaired; 
indeed,  at  times  having  a  hollow  or  tympanitic  quality. 

Second  stage,  dullness  over  the  affected  parts,  with  an  increased 
sense  of  resistance. 

Auscultation.  First  stage,  over  affected  part,  feeble  vesicular 
murinur,  associated  with  the  true  vesicular  or  crepitant  (crackling) 
rale,  most  distinct  during  inspiration. 

Second  stage,  harsh,  high-pitched  bronchial  respiration,  at  times 
resembling  a  to  and  fro  metallic  sound,  except  in  those  rare  instances 
in  which  the  bronchi  are  more  or  less  filled  with  secretion. 


DISEASES   OF  THE  LUNGS.  245 

Bronchophony,  or  distinctly  transmitted  voice,  at  \\m.es  pectoriloquy, 
or  distinct  transmission  of  articulated  sounds. 

Third  stage,  breathing  changing  from  bronchial  to  vesiculo-bron- 
chial,  the  crepitant  (crepitatio  redux)  rale  returning,  and  if  resolution 
proceed,  the  breath  sounds  are  associated  with  large  and  small  moist 
and  bubbling  rales. 

"  The  morbid  phenomena,  physical  signs  and  symptoms  of  the 
malady  correspond  usually  in  this  manner." — (Da  Costa.) 

I    Stage    of    engorgement    Crepitant  rale ;  slight  percus-    Cough:    beginning   dyspnoea 
and  beginning  exuda-        sion  dullness.  and  rapidly  developed  fever 

tion.  heat. 

II.  Stage  of  solidification  of  Percussion  dullness;  bron-  Rusty-colored  sputum  ;  dysp- 
lung-tissue  (red  hepat-  chial  respiration;  broncho-  noea ;  cough;  high  fever, 
ization).  phony.  with   marked    evening  ex- 

acerbations   and    morning 
remissions. 

III.  Stage  of  softening  (gray    The  same  physical  signs  as     Chills;  prostration,  etc.;  puru- 

hepatization).  in  the  second  stage,  unless        lent  or   brownish  sputum ; 

large  abscesses  have  formed.        generally  high  temperature. 

Terminations.  Asthenic  cases  recover  within  two  weeks.  When 
purulent  infiltration  supervenes,  the  disease  pursues  a  tedious  course 
of  several  weeks'  duration,  with  a  low  exhaustive  fever. 

If  death  occur  during  the  first  or  second  stages  it  is  usually  the 
result  of  a  collateral  cedema  of  the  uninflamed  lung,  or  cardiac  failure 
and  impaired  nerve  force. 

If  abscesses  occur,  there  are  exhaustion  sweats,  frequent  cough, 
with  a  large  amount  of  yellowish-gray,  at  times  blood-streaked, 
expectoration. 

Gangrene  of  the  lungs  is  a  rare  termination  ;  it  is  associated  with 
symptoms  of  collapse,  the  expectoration  of  a  blackish,  fetid  sputum, 
and  the  physical  signs  of  a  pulmonary  cavity. 

Diagnosis.  (Edema  of  the  lungs  may  be  confounded  with  the 
first  stage  of  pneumonia,  but  the  subsequent  history,  its  presence  on 
both  sides,  and  the  watery  expectoration  and  absence  of  chill  and 
pain  and  the  physical  signs  of  pneumonia  soon  determine  the 
diagnosis. 

Complications.  Acute  pleuritis  is  a  frequent  complication  of 
croupous  -pneumoniaj  occurring  as  often  as  from  ten  to  twenty-five 


246  PRACTICE   OF   MEDICINE. 

per- cent,  of  cases.  The  more  acute  localized  pain,  the  greater  em- 
barrassment of  respiration,  and  the  usual  physical  signs  of  effusion 
are  the  evidences  of  a  pleiiro-pneumonia. 

Capillary  bronchitis  is  a  rare  but  dangerous  complication. 

Pericarditis,  rheumatism  and  gout  are  rare  complications. 

Pleurisy  is  oftener  confounded  with  pneumonia  than  any  other  dis- 
ease, the  points  of  distinction  between  which  will  be  pointed  out  when 
discussing  that  affection. 

Prognosis.  Depends  upon  the  extent  of  the  inflammation,  the 
dangerous  features  of  croupous  pneumonia  being  cardiac  failure,  the 
result  of  the  embarrassed  respiratory  circulation,  and  the  rapid  tissue 
waste  associated  with  extreme  fever,  105°,  resulting  in  impaired  nerve 
force;  double  pneumonia  is  a  very  grave  prognosis,  but  is  not  nearly 
so  frequent  as  was  at  one  time  supposed.  The  co-existence  of  pleuritis 
adds  to  the  gravity  of  the  prognosis,  although  not  as  fatal  as  it  formerly 
was.  Pneumonia  of  drunkards  almost  invariably  terminates  fatally. 
Typhoid  pneumonia,  the  so-called  bihous  pneumonia,  purulent  infiltra- 
tion, abscesses  of  the  lungs  and  gangrene,  all  give  a  grave  prognosis. 

Treatment.  If  pneumonia  be  regarded  as  a  constitutional 
malady  with  a  local  lesion,  then  the  consolidated  lung  no  more  calls 
for  treatment  than  does  the  intestinal  ulcer  of  typhoid  fever,  but  the 
general  condition  of  the  patient  is  to  govern  in  the  management  of 
the  case  and  not  the  local  changes  going  on  in  the  thorax.  A  simple 
pneumonia  attacking  persons  previously  in  good  health  requires  no- 
more  active  treatment  than  any  of  the  so-called  self-limited  diseases, 
provided  only  that  the  extent  of  the  disease  be  moderate,  and  there 
be  no  complication. 

The  much  discussed  question  of  venesection  is  now  a  settled  prob- 
lem in  the  affection  ;  if  we  bleed  it  is  "  not  because  of  pneumonia,  but  in 
spite  0/ pneufnonia."  Called  to  a  case  in  the  first  stage  of  the  disease, 
or  early  in  the  second  stage,  who  has  been  vigorous  and  otherwise 
healthy,  with  a  high  temperature,  105°  or  more,  with  frequent  pulse, 
one  hundred  and  twenty  beats  or  more,  or  a  slow,  full  pulse  showing 
cardiac  oppression,  flushed  surface  and  marked  dyspnoea,  a  copious 
bleeding  is  indicated,  and  the  same  may  be  said  when  symptoms  of 
collateral  oedema  threaten ;  this  is  bleeding  for  symptoms  and  not  for 
the  disease  per  se. 

Called  to  the  majority  of  cases,  during  the  first  stage,  after  a  rapidly 
acting  purgative,  administer  quinines  sulphas,  gr.  v,  with  or  without 


DISEASES   OF  THE   LUNGS.  247 

antipyrine,  gr.  iij-v,  every  three  hours  until  their  effects  are  produced, 
using  at  the  same  time  small  doses  of  such  arterial  sedatives  as 
aconitum,  veratruin  viride  or  digitalis  until  a  decided  impression  is 
made  on  the  circulation.  It  is  also  in  this  stage  that  either  wet  or  dry- 
cups  over  the  chest,  followed  by  the  application  of  poultices,  seems 
to  act  beneficially.  In  the  feeble  or  aged  poultices  are  to  be  used 
from  the  onset. 

Second  stage.  It  is  at  this  period  of  a  severe  attack  of  acute  pneu- 
monia that  two  prominent  indications  for  treatment  arise, — heart- 
insufficiency  and  high  temperature. 

To  reduce  the  temperature,  we  have  at  least  two  safe  and  reliable 
drugs,  if  administered  in  sufficient  amounts.  I  refer  to  quinince  sulphas 
and  antipyrine.  The  dose  of  quininae  sulphas  as  an  antipyretic  in 
pneumonia  is  gr.  x-xv,  repeated  as  needed.  The  doses  of  thirty  and 
forty  grains  recommended  I  have  never  seen  required ;  in  fact,  it 
would  seem  to  me  to  be  contraindicated  on  account  of  the  cardiac 
depression  such  amounts  would  produce.  Antipyrine  is  also  a  very 
reliable  antipyretic  either  alone  or  combined  with  the  quinine.  The  use 
of  the  cold  pack  or  of  cold  baths  for  reducing  the  temperature  in  acute 
pneumonia  has  not  met  with  the  approval  of  practical  clinicians. 

To  sustain  the  heo^rt  is  one  of  the  most  important  indications  in  the 
treatment  of  acute  pneumonia,  for  experience  shows  that  cardiac 
failure  is  responsible  for  a  large  number  of  deaths  in  this  affection. 
Without  question,  alcoholic  stimulants  judiciously  employed  are  the 
most  efficient  means  for  preventing  or  overcoming  the  cardiac  failure. 
The  amount  can  only  be  determined  by  a  careful  study  of  each  case, 
as  a  few  ounces  in  the  twenty  hours  may  answer  in  one  case,  while 
another  may  require  eight  or  ten  ounces.  It  is  well  to  begin  with 
small  doses,  increasing  or  decreasing  as  its  effects  are  good  or  bad. 

The  indicator  of  the  heart's  condition  is  the  pulse.  In  the  aged,  the 
feeble,  or  in  those  accustomed  to  the  use  of  alcohol,  stimulation  is 
indicated  from  the  onset.  Other  indications  would  be  a  frequent, 
feeble,  irregular  or  intermitting  pulse;  a  dicrotic  pulse;  delirium, 
muscular  tremor  and  subsultus ;  immediately  following  crisis,  and  the 
period  of  collapse. 

Other  cardiac  stimulants  that  may  be  used  are  ammonii  carbonas, 
digitalis  and  moschus. 

It  is  also  during  this  period  that  the  diet  must  be  of  the  most  nutri- 
tious but  easily  digestible  character,  and  given  at  periods  of  every 
three  hours. 


248  PRACTICE   OF   MEDICINE. 

Third  stage.  The  treatment  is  a  continuation  of  the  second  stage, 
gradually  reducing  the  antipyretics  as  the  fever  declines,  and  adding 
one  of  the  preparations  oi  ferrum. 

Convalescejice.  Nutritious  diet,  quininae  sulphas  in  tonic  doses, 
ferrum,  together  with  a  good  blood-making  wine  or  a  good  prepara- 
tion of  malt.  If  the  consolidation  shows  a  disposition  to  linger, 
blisters  may  be  used. 

The  various  symptoms  other  than  those  particularly  mentioned  are 
to  be  met,  as  they  arise,  by  their  proper  remedies. 

For  typhoid  pneumonia,  purulent  infiltration,  abscess  of  the  lungs, 
or  pneumonia  in  drunkards,  the  weak  or  the  aged,  quinina,  ferrum, 
nutritious  diet  and  bold  stimulation,  and  the  free  use  of  aminonii 
carbonas  are  the  indications. 

The  so-called  antiseptic  treatment  of  acute  pneumonia  is  still  under 
trial,  and  no  definite  opinion  can  be  expressed  concerning  it. 

CATARRHAL  PNEUMONIA. 

Synonyms.  Broncho -pneumonia;  lobular  pneumonia;  capillary 
bronchitis  (?), 

Definition.  An  acute  catarrhal  inflammation  of  the  bronchioles 
and  alveoli  of  the  lungs  characterized  by  fever,  cough,  dyspnoea, 
copious  expectoration  and  great  depression. 

Causes.  From  an  extension  of  a  bronchial  catarrh  downward ; 
following  the  eruptive  fevers,  especially  measles;  complicating  whoop- 
ing cough.  Persons  of  the  rickety  or  scrofulous  diathesis,  in  whom 
there  is  a  greater  irritability  of  the  epithelial  elements,  are  particularly 
predisposed  to  this  form  of  pneumonia  on  slight  exposure ;  emphy-r 
sema ;  diseases  of  the  heart ;  most  frequently  seen  in  childhood  and 
old  age. 

Pathological  Anatomy.  Hypercemia  of  the  mucous  membrane 
of  the  bronchi,  and  also  of  the  bronchioles  and  air  cells,  with  swelling 
and  succulence  of  these  tissues,  accompanied  by  an  abnormal  secretion 
and  an  immense  production  of  young  cells  from  the  proliferation 
of  the  bronchial  and  alveolar  epithelium,  admixed  with  a  yellowish, 
creamy,  mucoid  material,  which  blocks  up  the  bronchioles  and  air 
cells. 

The  affected  parts  first  have  a  reddish-gray,  soon  changing  to  a 
yellowish-gray  color,  due  to  the  rapid  metamorphosis  of  the  newly 


DISEASES   OF   THE    LUNGS.  249 

developed  cells.  If  the  fatty  change  be  completed,  absorption  takes 
place,  and  the  consolidation  is  removed  ;  if  it  remain  incomplete  the 
cells  atrophy,  the  little  mass  becoming  caseous,  and  the  disease 
passes  into  a  chronic  state. 

The  bronchial  tubes  also  participate  in  the  disease,  the  walls  become 
thickened,  from  a  hyperplasia  of  the  connective  tissue  {peri-bronchi- 
tis), and  their  calibre  is  often  dilated. 

Symptoms.  Catarrhal  pneumonia  begins  as  a  catarrhal  bron- 
chitis.    It  may  be  either  actite,  sub-acute  or  chronic  in  its  course. 

Acute  variety  :  Its  onset  is  announced  by  a  gradual  rise  of  tempera- 
ture to  io2°-i03°  F.,  the  febrile  phenomena  assuming  atypical  remit- 
tent character,  with  rapid,  laborious  and  shallow  breathing,  as  shown 
by  the  widely  dilated  nares  and  violent  action  of  all  the  accessory 
muscles,  while  the  insufficient  distention  of  the  lungs  is  shown  by 
the  great  recession  of  the  lower  part  of  the  chest  walls  and  sinking 
in  of  the  intercostal  spaces.  The  inspiration  is  short  and  imperfect, 
the  expiration  noisy  and  prolonged  ;  ih.^  pulse  isfrequefit,  100-120  or 
more,  and  somewhat  compressible  ;  the  cough,  which,  during  the 
bronchitis,  was  loose,  now  becomes  short,  hacking,  dry  and  painful, 
soon  followed  by  more  or  less  copious  muco-purulent  expectoration  ; 
the  appetite  is  impaired,  bowels  somewhat  loose,  urine  scanty,  high- 
colored,  and  the  surface  frequently  covered  with  a  more  or  \qs'S>  prof  use 
perspiration. 

The  sub-acute  and  chronic  varieties  have  the  same  general  symp- 
toms, but  the  duration  is  longer  and  the  exhaustion  greater. 

The  progress  of  catarrhal  pneumonia  is  sometimes,  although  not 
often,  a  very  acute  one.  The  disease  may  prove  fatal  in  a  few  days, 
especially  if  it  attack  feeble  children;  in  such  the  countenance 
becomes  pale  and  livid,  the  lips  bluish,  the  eyes  dull,  and  a  rest- 
lessness giving  place  to  apathy  and  a  continually  augmented 
somnolence. 

Resolution,  when  it  occurs,  is  by  lysis,  several  weeks  elapsing  before 
complete  recovery. 

Percussion.  Dullness,  scattered  in  patches,  over  both  lungs,  the 
intervening  healthy  lung  often  giving  a  more  or  less  hollow  or  tynt- 
panitic  note. 

Auscultaiion.      Vesiciilo-bronchialhxe.2lh\ng,  changing  to  moist 
bronchial  breathing,  associated  with  small  bubbling  (sub  crepitant) 
rales.     As  the  disease  progresses  toward  resolution,  the  rales  become 
21 


250  PRACTICE   OF   MEDICINE. 

larger  (large  bubbling)  and  more  copious.  If  pneumonic  phthisis 
result,  physical  signs  indicative  of  that  condition  are  soon  evident. 

Sequelae.  Attacks  of  catarrhal  pneumonia  complicated  with 
atelectasis,  or  collapse  of  the  lobules,  when  recovery  occurs,  are  fol- 
lowed by  emphysema  of  the  lungs. 

If  the  catarrhal  products  which  fill  the  alveoli  and  bronchioles  and 
intervening  connective  tissue  do  not  rapidly  undergo  complete  fatty 
metamorphosis  and  consequent  absorption,  pneumonic  phthisis 
results. 

Diagnosis.  Ordinary  broiichial  catarrh  differs  from  catarrhal 
pneumonia  by  the  absence  of  dyspnoea,  fever,  and  dullness  on  per- 
cussion, and  the  presence  of  the  large  bubbling  rales,  and  also  by  the 
subsequent  history  of  the  two  affections. 

Croupous  pneumonia  is  a  unilateral  disease  ;  catarrhal  pneumonia 
is  bilateral  and  diffused  over  both  lungs  ;  the  former  a  self-limited 
disease,  the  latter  having  no  fixed  duration. 

Acute  tuberculosis  at  its  onset  is  characterized  by  the  presence  of  a 
capillary  bronchitis,  a  differentiation  being  possible  only  by  a  study 
of  the  clinical  history  and  course  of  the  two  maladies. 

CEdema  of  the  lungs  is  a  bilateral  disease  associated  with  a  short, 
dry  cough  and  dyspnoea,  but  lacks  the  previous  catarrhal  history  and 
high  temperature  of  catarrhal  pneumonia. 

Prognosis.  Fully  one-half  of  the  cases  of  true  catarrhal  pneu- 
monia terminate  fatally.  The  prognosis  must  be  guarded  in  scrofu- 
lous or  rachitic  subjects,  or  those  enfeebled  by  other  diseases,  for, 
unless  prompt  resolution  can  be  effected,  it  will  terminate  fatally 
early,  or  develop  pneumonic  phthisis.  Have  seen  cases  continuing 
up  and  down  for  eight  and  ten  months,  and  finally  make  a  good 
recovery. 

Treatment.  Confinement  to  bed  is  paramount,  although  the 
position  of  the  patient  is  to  be  frequently  changed.  The  diet  must  be 
of  the  most  nutritious  character,  administered  at  frequent  intervals  ; 
milk,  eggs,  chicken,  beef,  mutton  and  oyster  broths  are  the  most  suit- 
able. The  steady  use  of  brandy  or  whisky  throughout  the  attack  is 
of  importance,  regulating  the  amount  by  the  age  of  the  patient  and 
the  severity  of  the  attack. 

For  the  fever,  quinines  sulphas,  gr.  xv-xx  each  day,  is  the  most  re- 
liable of  all  antipyretics,  or  antipyrine  in  full  doses  may  be  substituted. 

For  the  catarrhal  process,  the  air  of  the  apartment  should  be  main- 


DISEASES   OF   THE   LUNGS.  251 

tained  at  an  even  temperature  and  moistened  by  disengaging  the 
vapor  of  water  in  it.  The  following  combination  is  of  great  utility  in 
nearly  all  cases,  regulating  the  dose  in  accordance  with  the  age  of  the 
patient : — 

R .     Ammonii  carbonat., gr.  v 

Ammonii  iodidi. gr.  v-x 

Mucil.  acacise, q.  s. 

Syr.  glycyrrh., 3J-ij 

Syr.  prun.  virg., q.  s.    ad  gij-iv.  M. 

SiG. — Every  three  hours.  - 

A  much  pleasanter  way  of  administering  the  ammonia  salts  is  in 
capsules,  each  containing  about  two  and  one-half  grains  of  each  salt 
with  an  aromatic  oil.  Terpene  hydrate  acts  remarkably  well  in  many 
cases. 

For  convalescence,  nutritious  food,  ferri  iodidtim,  quinmcE  sulphas, 
and  oleum  morrhucB. 

Locally  :  repeated  application  of  mustard  poultices  or  turpentine 
stupes  followed  by  demulcent  poultices.  If  the  inflammatory  process 
tends  to  become  chronic,  scattering  blisters  should  be  used. 

PULMONARY  CONSUMPTION. 

Synonyms.     Phthisis  pulmonalis  ;  phthisis  ;  consumption. 

Definition.  Four  varieties  of  pulmonary  consumption  are  now 
admitted  to  exist :  Pneumonic  phthisis ;  tubercular  phthisis ;  fibroid 
phthisis ;  acute  miliary  tuberculosis. 

As  these  forms  present  differences  at  all  points,  they  will  be  de- 
scribed separately. 

PNEUMONIC  PHTHISIS. 

Synonyms.  Chronic  catarrhal  pneumonia ;  catarrhal  phthisis  ; 
caseous  pneumonia;  caseous  phthisis. 

Definition.  A  form  of  pulmonary  consumption  characterized  by 
the  destruction  of  the  pulmonary  tissue  resulting  from  the  caseation 
or  cheesy  degeneration  of  inflammatory  products  in  the  lungs  and 
the  subsequent  softening  and  destruction  of  the  caseous  matter,  with 
greater  or  less  destruction  of  the  pulmonary  tissue  ;  characterized  by 
hectic  fever,  cough,  shortness  of  breath,  purulent  expectoration,  and 
more  or  less  rapid  prostration. 


252  PRACTICE   OF   MEDICINE. 

• 

Causes.  The  predisposing  factor  in  the  etiology  of  pneumonic 
phthisis  is  a  strumous  or  scrofulous  diathesis,  or  a  condition  of  lowered 
health,  the  result  of  various  unfavorable  hygienic  influences. 

The  exciting  causes  are  catarrhal  pneumonia  in  any  portion  of  the 
lung,  but  especially  at  the  apex ;  inflammation  occurring  about  a 
blood  clot ;  inhalation  of  irritant  particles  occurring  in  certain  occu- 
pations, to  wit :  weaving,  grinding,  mining,  hatters,  millers,  cigar 
makers,  and  the  like. 

Pathological  Anatomy.  When  a  pneumonia  terminates  in 
resolution  the  inflammatory  products  are  absorbed  by  first  undergoing 
2i  fatty  meiatnorp/iosis.  If  the  fatty  metamorphosis  be  incomplete,  the 
cells  are  atrophied  and  undergo  the  caseous  degeneration,  which  con- 
sists in  the  absorption  of  the  watery  parts  and  the  fatty  degeneration 
of  the  cellular  elements  and  the  granular  disintegration  of  the  fibrin- 
ous material,  so  that  ultimately  a  soft,  solid  mass  is  produced,  yellow- 
ish in  color,  having  the  appearance  of  cheese. 

The  destructive  changes  are  thus  described  by  Niemeyer  :  "  Cells, 
the  products  of  inflammation,  accumulate  in  the  alveoli  and  minute 
bronchi,  crowd  upon  each  other,  becoming  densely  packed,  and  thus 
by  their  mutual  pressure  they  bring  about  their  own  decay,  as  well  as 
that  of  the  lung  textures,  by  interfering  with  their  nutrition,  the  alveolar 
walls  being  also  themselves  damaged  by  the  inflammatory  process." 

The  position  of  the  catarrhal  pneumonia  resulting  in  the  above 
changes  is  usually  at  the  apex,  but  it  may  occur  at  any  portion  of  the 
lungs,  or  a  whole  lung  becomes  infiltrated,  and  undergoes  the  cheesy 
degeneration  (phthisis  florida). 

In  many  cases  tubercle  is  deposited  in  the  inflamed  lung,  hastening 
its  destruction  and  the  formation  of  cavities. 

Symptoms.  Pneumonic  phthisis  occurs  in  three  forms,  the 
chronic,  the  sub-acute  and  the  acute. 

Chronic  form.  The  origin  is  rather  insidious,  the  individual  being 
susceptible  to  "  colds,"  or  "  catarrhs,"  on  the  slightest  exposure ;  grad- 
ually a  persistent  cough,  with  the  expectoration  of  muco-pus,  is  estab- 
lished, each  severe  cold  being  accompanied  with  cJiill,  fever, 
pain  in  the  chest,  and  either  slight  hemorrhage  or  blood-streaked 
sputa.  Finally  the  catarrhal  symptoms  become  persistent,  with 
morning  chills,  evening  fevers  and  rather  profuse  flight  sweats,  dis- 
tressing cough,  profuse  muco-purulent  sputa,  great  weakness  and 
exhaustion,   loss   of  appetite   and   feeble   digestion,   the   symptoms 


DISEASES   OF  THE    LUNGS.  253 

growing  persistently  worse,  death  occurring  from  exhaustion  after  one 
or  two  years'  duration. 

Sub-acute  variety.  History  of  an  acute  attack  of  pneumonia  of  one 
or  two  weeks'  duration,  followed  by  a  decided  improvement,  but  not 
complete  recovery.  After  a  lapse  of  some  weeks  or  months,  symp- 
toms of  pulmonary  softening  begin,  destroying  the  lung  structure  and 
forming  cavities,  accompanied  by  chills,  fever,  7iight  sweats,  emaci- 
ation, cough,  muco-purtilent  and  blood-streaked  expectoration,  the 
patient  dying  from  exhaustion  within  a  year. 

Acute  variety,  the  so-called  phthisis  florida,  runs  a  rapid  course, 
beginning  as  a  catarrhal  pneumonia,  involving  the  whole  of  one  or 
part  of  both  lungs,  associated  with  rapid  loss  of  flesh  and  strength, 
high  but  variable  temperature,  I03°-I05°  F.,  with  remissions,  profuse 
night  sweats,  shortness  of  breath,  severe  cong'n.,  profuse,  purulent  and 
blood-streaked  sputa,  loss  of  appetite,  feeble  digestion,  rapid  emaciation, 
the  patient  succumbing  in  a  few  weeks  or  months,  from  exhaustion. 

A  decided  remission  in  the  local  and  general  symptoms  of  the  acute 
variety  may  occur,  the  disease  afterward  pursuing  a  more  chronic 
course. 

Inspection.  Shows  deficient  respiratory  movements  of  the  dis- 
eased portion  of  the  lungs. 

Palpation.  Increased  vocal  fremitus  over  the  consolidated  lung 
tissue  and  cavities. 

Percussion.  The  percussion  note  varies  from  a  slight  impair- 
ment oi  the  normal  note  to  dullness,  and  when  cavities  are  formed, 
associated  with  scattered  points  of  the  tympa7iitic  or  hollow  note.  If 
the  cavities  communicate  with  a  bronchial  tube  the  cracked-pot  or 
cracked-?netal  sound  is  elicited.  If  the  cavities  are  filled  with  pus  the 
percussion  note  is  dull.  If  the  pus  be  expelled,  the  tympanitic  or 
cracked-pot  sound  returns. 

Auscultation.  The  vesicular  murmur  is  unimpaired  in  those 
parts  free  from  disease  :  it  is  feeble  or  indistinct  if  many  bronchioles 
are  obstructed  ;  and  is  harsh  or  blowing  if  the  bronchioles  are  nar- 
rowed. The  inspiratory  sound  will  be  jerking,  and  the  expiratory 
sound  prolonged  and  blowifig  when  the  lung  has  lost  its  elasticity. 

Associated  with  the  impaired  vesicular  murmur  is  2,  fine,  dry,  crack- 
ling sound  (crepitation),  appearing  at  the  end  of  inspiration.  If  bron- 
chitis be  associated,  large  and  small  moist  or  bubbling  rales  are  heard 
during  the  respiration. 


254  PRACTICE   OF   MEDICINE. 

When  cavities  form,  either  bronchial  or  broncho-cavernotis  respira- 
tion is  heard,  associated  with  more  or  less  distinct  gurg/ing  rales. 
If  the  cavity  be  free  from  pus  and  have  rather  firm  walls,  the  breath- 
ing is  more  amphoric  in  character. 

Diagnosis.  Catarrhal  bronchitis  has  many  points  of  resemblance 
to  pneumonic  phthisis.  The  subsequent  course  of  the  latter,  with  the 
high  temperature,  prostration,  emaciation,  and  physical  signs,  should 
prevent  error. 

Tubercular  phthisis  is  often  confounded  with  pneumonic  phthisis, 
an  error  difficult  to  prevent  in  many  cases. 

Prognosis.  Acute  variety,  the  phthisis  florida,  usually  terminates 
fatally  within  a  few  months. 

The  sub-acute  and  chronic  varieties  may,  under  judicious  treatment 
and  favorable  hygienic  conditions,  be  arrested,  the  caseous  matter 
partly  expectorated  and  partly  absorbed,  leaving  more  or  less  loss  of 
structure,  cicatricial  tissue  supplying  its  place,  which  after  a  time  con- 
tracts, causing  more  or  less  contraction  of  the  chest  walls. 

Cases  not  properly  treated,  either  from  carelessness  or  poverty,  suc- 
cumb after  a  year  or  two. 

Treatment.  An  attempt  should  always  be  made  to  remove  the 
caseous  matter  by  absorption  and  expectoration.  The  following  pre- 
scriptions will  sometimes  prove  successful  : — 

R  .     Ammon.  carb., gr.  v 

Ammon.  iodidi, gr.  v-x 

Syr.  tolu, 5  ij 

Syr.  prun.  virg., ^ij.  M. 

Every  five  hours,  alternating  with 

R.     Liq.  p';tassii  arsenitis, TT^v 

Mass.  ferri  carb., gr-  v 

Vini  xerici, '7^\ 

Aquae  dest., q.  s.  ad  f^ss.  M. 

The  diet  should  be  of  the  most  nutritious  character,  the  clothing 
warm,  and,  if  practicable,  change  of  residence  should  be  made  to  a 
dry  and  elevated  climate.  If  the  digestion  will  permit,  oleum  mor- 
rhucE^  3j-Jj.  three  times  a  day. 

For  the  fever,  quinines  sulphas,  gr.  xv-xx,  is  more  successful  than 
the  combination  of  quinina  and  digitalis  in  small  doses  ;  experience 
has  demonstrated  that  the  antipyretic  properties  of  quinina  are 
markedly  increased  if  rest  in  bed  for  the  time  being  be  enjoined. 


DISEASES    OF   THE   LUNGS.  255 

Loomis  has  found  that  the  antipyretic  properties  of  quinina  in  phthisis 
are  increased  by  the  addition  of  morphina  to  each  dose. 

Night  sweats  are  best  controlled  by  atropitice  sulphas,  gr.  -g-^-,   at 
bedtime,  or 

R.     Extract,  belladonnje, gr.  ss 

Zinci  oxidi, gr.  iij-  M. 

At  bedtime. 

For  the  cough  and  sleeplessness,  codeines  sulphas,  gr.  ss-j,  p.  r.  n. 


TUBERCULAR  PHTHISIS. 

Synonyms.     Tuberculosis  ;  consumption  ;  incipient  phthisis. 

Definition.  The  deposition  of  tubercle  in  the  lung  structure, 
which  undergoes  softening,  followed  by  more  or  less  loss  of  the  pul- 
monary tissue  proper ;  characterized  by  fever,  cough,  dyspnoea,  ema- 
ciation and  exhaustion. 

Causes.  Chiefly  hereditary  ;  closely  associated  with  scrofula  and 
struma  ;  probably  contagious  under  certain  conditions;  secondary  to 
catarrhal  (caseous)  pneumonia;  the  theory  of  the  "bacillus  ticbercu- 
losis''  of  Koch  is  still  subjudice. 

Patholog'ical  Anatomy.  Tubercle  is  a  grayish-white,  trans- 
lucent and  semi-solid  granulation,  about  the  size  of  a  millet  seed, 
most  commonly  deposited  in  the  walls  of  the  bronchioles,  exciting  a 
low  form  of  inflammation,  the  result  of  its  own  death.  The  masses 
of  tubercle  soon  undergo  softening  (cheesy  transformation)  ;  the  lung 
structure  is  secondarily  affected,  undergoes  softening,  which  results 
in  more  or  less  destruction  of  the  tissue,  whence  cavities  are  formed. 

The  inflammation  may  extend  to  the  small  arteries,  causing  hem- 
orrhage. 

The  deposit  of  tubercle  is  generally  at  one  of  the  apices,  soon 
spreading  toother  parts;  depositions  may  also  occur  in  the  brain, 
intestines  and  liver. 

The  pleura  is  usually  the  seat  of  a  chronic  inflammation  (dry  pleu- 
risy), resulting  in  the  obliteration  of  the  pleural  cavity. 

Symptoms.  The  symptoms  correspond  closely  to  the  stages  of 
deposition,  of  softening,  and  of  the  formation  of  cavities. 

The  development  is  insidious,  with  increasing  dyspepsia,  irritable 
heart,  a  light,  dry,  hacking  cough,  referred  to  the  throat  or  stomach. 


256  PRACTICE   OF   MEDICINE. 

scanty,  glmry  ex/>ecfora/ion,gr3.dua.\  loss  of  weight,  impaired  muscular 
strength,  pallid  appearance,  xv^ox^  or  less  copious  hcemoptysis  Q){x.^rv 
following.  Pain,  sharp  in  character,  below  the  clavicles,  is  often 
present. 

The  beginning  of  softening  is  announced  by  increased  cough,  freer 
expectoration,  dyspnoea  increased  on  exertion,  w\oxnmgchil/s,  evening 
fez'er,  night  sweats — the  so-called  hectic  fever,  diarrhoea,  increased 
emaciation  and  weakfiess,  the  patient,  however,  continuing  very 
hopeful. 

With  i\\&  formation  of  the  cavities,  the  cough  is  more  aggravated, 
with  profuse  and  purulent  expectoration,  at  times  containing  yellow 
striae,  the  amount  depending  upon  the  number  and  size  of  the  cavi- 
ties ;  haemoptysis  not  common  at  this  stage  ;  the  pulse  rapid  and 
weak,  increased  hectic,  burning  of  the  soles  and  palms,  copious  7tight 
sweats,  greater  debility  and  emaciation,  with  osdema  of  the  feet  and 
ankles,  denoting  failure  of  the  circulation,  death  soon  following  from 
asthenia,  the  mind  clear  and  hopeful  to  the  end. 

Inspection.  First  stage,  often  shows  slight  depressio?ts  in  the 
supra-clavicular,  and   at  times  in  the  infra-clavicular  regions. 

Palpation.     Second  stage,  the  vocal  fremitus  is  slightly  increased. 

Percussion.  First  stage,  slight  impairment  of  the  normal  per- 
cussion resonance  can  sometimes  be  elicited.  Seco?id  stage,  the 
resonance  is  impaired,  and  may  be  even  dull.  Third  stage,  dullness 
with  circumscribed  spots  of  the  amphoric,  or  tympajiitic  or  cracked- 
pot  sound. 

Auscultation.  First  stage,  inspiration  jerky,  expiration  pro- 
longed, the  pitch  higher  than  normal,  the  inspiration  associated  with 
crackling  rales. 

Second  stage,  vesiculo-branchialhrQ2i\h\ng,  associated  with  sub-crepi- 
tant  and  large  and  moist  or  bubbling  tales. 

Third  stage,  bronchial,  bro7icho-cavernous  and  cavernous  respira- 
tion, associated  with  large  and  small  moist  or  bubbling,  and  localized 
gurgling  rales. 

Bronchophony  in  its  various  degrees  is  associated  with  the  second 
and  third  stages  of  tuberculosis. 

Complications.  Tubercular  diseases  of  the  brain,  larynx,  pleura, 
intestines  and  peritoneum  ;  perineal  abscess  leading  to  fistula. 

Diagnosis.  The  early  diagnosis  of  tubercular  phthisis  rests 
mainly  on  the  history,  together  with  the  symptoms  and  physical  signs. 


DISEASES   OF  THE   LUNGS.  257 

In  the  first  stage  it  is  often  mistaken  for  dyspepsia,  anaemia,  malarial 
fever,  or  disease  of  the  heart. 

Prognosis.  In  the  main  unfavorable,  although  under  proper 
treatment,  change  of  climate  and  like  favorable  conditions  life  may- 
be prolonged  for  years.  The  question  of  perfect  recovery  is,  to  say 
the  least,  doubtful. 

Treatment.  While  I  have  never  seen  a  case  of  incipient  phthisis 
cured,  in  the  broad  acceptation  of  that  term,  I  have  repeatedly  seen 
life  prolonged  for  a  number  of  years,  and  the  deposition  of  tubercle 
long  delayed  by  a  change  of  climate  early  in  the  history  of  the  case, 
warm  clothing,  life  and  exercise  in  the  open  air  short  of  fatigue,  and 
systematic  bathing  and  a  nutritious  plan  of  dieting.  If  the  diet  is 
arranged  in  accordance  with  the  appetite,  the  latter  will  gradually 
increase,  but  should  it  not,  it  may  be  stimulated  by  such  bitters  as 
nucis  voinicis,  ignatia  a7?iara,  Colombo  ox  gentian. 

The  sym.ptoms  are  to  be  met  as  they  arise,  and  drugs  are  not  to  be 
used  simply  because  the  patient  has  the  physical  signs  of  beginning 
tubercle.  For  the  general  debility  and  malaise  that  accompanies  the 
early  stages  of  this  malady,  any  one  or  a  combination  of  the  follow- 
ing drugs,  exercising  care  that  they  in  no  way  interfere  with  the 
appetite  :  01.  morrhucE,  ferri  iodidum,  arsenicum,  hypophosphites,  or 
the  elixir  quitiina  ferri  et  strychnin  a. 

Great  temporary  improvement  in  the  symptoms  of  phthisis  some- 
times follows  the  rectal  injection  of  stilphuretied  hydrogen  after  the 
manner  suggested  by  M.  Bergeon,  of  Paris,  but  that  recovery  will 
occur  is  hardly  probable. 

Dr.  H.  C.  Wood  suggests  the  administration  of  the  remedy  by  the 
stomach,  claiming  as  great  success  by  that  means  as  when  admin- 
istered per  rectum.  To  cover  the  disagreeable  taste  of  the  remedy 
he  uses  a  saturated  solution  of  the  sulphuretted  hydrogen,  using  :  "At 
first  half  an  ounce,  afterwards  an  ounce,  of  the  saturated  solution  of 
the  sulphuretted  hydrogen  should  be  placed  in  a  tumbler,  and  two 
or  three  ounces  of  carbonic  acid  water  be  run  into  it  from  a  highly- 
charged  siphon,  the  whole  being  drunk  while  effervescing.  This  may 
be  given  three  to  five  times  a  day,  so  that  the  patient  will  receive  daily 
between  half  a  pint  and  a  pint  of  the  sulphuretted  hydrogen  gas." 

Special  symptoms  require  treatment  only  when  indicated,  care 
being  exercised  to  avoid  everything  which  tends  to  impair  the  appe- 
tite, disorder  digestion,  or  lower  the  vital  powers. 


258  PRACTICE   OF   MEDICINE. 

For  the  y^T^^r  the  "  Niemeyer  pill"  is  usually  recommended;  its 
formula  being — 

R.     Quinincesulph., gr.  j 

Pulv.  digitalis, gr.  ss 

Pulv.  opii,        £•"•  X 

Pulv.  ipecac,        S^-  ^-  ^^• 

From  a  very  considerable  experience  with  this  "famous"  pill,  I 
can  recall  few  cases  in  which  it  has  proven  of  the  least  benefit.  The 
following  is  much  more  effectual :  — 

li  .     Quininre  sulph., gf-  x 

Quininae  muriat., gr.  x 

Pulv.  opii  et  ipecac, g''- i'j-  M. 

Ft.  capsul  No.  ij. 

SiG. — One  capsule  five  hours,  and  the  other  three  hours  before  the  de- 
cided rise  of  temperature. 

For  «/>///  sweats,  not  the  result  of  the  diurnal  fever,  atropince 
sulphas,  gr.  ^^o~iV'  at  bedtime,  is  an  effective  agent.  It  is  claimed  that 
sulphonal,  gr.  vij-x,  at  bedtime,  controls  the  night  sweats  and  also 
produces  a  quiet,  refreshing  sleep. 

For  cough,  if  not  modified  by  the  arrest  of  temperature  and  night 
sweats,  the  following  is  of  use  : — 

Ijt.     Codeince  sulphat., gr.  ^-^ 

Acid,  hydrocyanici  dil.,      TT\^ij 

Syr.  lolu,      5J.  M. 

SiG. — Several  times  a  day. 

The  ^i/J^/Z/r symptoms  are  wonderfully  relieved  by  the  following : — 

R  .     Pepsini  cryst., gr.  ij 

Acid,  muriat.  dil., rr\^x 

Glycerini, TT^xx 

Succi  liminos, Ti:\^xv 

Aqua,' aurantii  flor.  ad, ^ij.  M. 

SiG  — Whh  meals. 


FIBROID  PHTHISIS. 

Synonyms.  Chronic  interstitial  pneumonia;  cirrhosis  of  the 
lungs ;  Corrigan's  disease. 

Definition.  A  hyperplasia  (thickening)  of  the  pulmonary  con- 
nective tissue,  resulting  in  atrophy  and  degeneration  of  the  vesicular 


DISEASES   OF  THE   LUNGS.  259 

Structure,  associated  with  bronchial  inflammation  ;  characterized  by- 
cough,  profuse  expectoration,  fever,  emaciation,  and  ultimately  death 
by  asthenia. 

Causes.  Hereditary  ;  inhalation  of  irritants  ;  chronic  bronchitis  ; 
alcoholism. 

Patholog'ical  Anatomy.  Thickening  of  the  bronchial  mucous 
membrane  and  dilatation  of  the  air  tubes ;  hyperplasia  of  the  pulmon- 
ary connective  tissue,  resulting  in  the  compression  and  consequent 
destruction  of  the  vesicular  structure,  which  is  assisted  by  the  contrac- 
tion of  the  newly  formed  tissues.  Sooner  or  later  catarrhal  pneu- 
monia results,  the  product  undergoing  the  cheesy  degeneration,  cavi- 
ties being  formed,  and  as  a  result  of  the  long-continued  suppuration 
tubercular  depositions  occur,  hastening  the  destruction  of  the  lung 
tissue. 

Prof.  Da  Costa  has  reported  a  number  of  cases  of  "grinders' 
phthisis,"  in  whose  sputum  was  found  the  "bacillus  tuberculosis,"  in 
whose  family  history  there  were  no  traces  of  consumption. 

Symptoms.  The  course  is  chronic,  beginning  as  a  bronchial 
catarrh,  worse  in  winter,  better  in  summer,  when,  after  several  years, 
the  cough  becomes  more  continuous,  the  expectoration  freer  and 
muco-purulent,  often  raised  in  paroxysms,  in  large  amounts,  hectic 
fever  develops,  7iight  sweats ,  dyspnoea  and  rapid  emaciation,  soon  fol- 
lowed by  cedema  of  the  feet  and  ankles,  the  result  of  failing  circula- 
tion, death  occurring  by  asthenia. 

Inspection.     Depression  of  the  chest  walls. 

Percussion.  Impaired  resonance,  followed  by  dullness,  with 
irregular  spots  of  amphoric  or  tyrnpatiitic  percussion  note  over  the 
points  of  depression. 

Auscultation.  First  stage,  vesiculo-bronchial,  or  harsh  respira- 
tion associated  with  large  and  small,  moist  or  bubbling  rales,  followed 
by  bronchial,  broiicho-cavernous  and  cavernous  respiration,  with  cir- 
cumscribed gurgling  rales. 

Diag'nosis.  Beginning  as  a  bronchial  catarrh,  slowly  progressing, 
with  the  remission  of  the  symptoms  during  the  summer  months, 
finally  becoming  progressively  worse,  with  the  formation  of  cavities, 
and  symptoms  of  asthenia,  are  the  chief  points  in  the  diagnosis. 

Prog'nosis.  The  duration  of  fibroid  phthisis  is  most  protracted, 
six  or  twelve  years  being  the  average  duration  ;  death,  however,  is 
the  inevitable  termination. 


260  PRACTICE   OF   MEDICINE. 

Prof.  Da  Costa  has  records  of  one  hundred  deaths  from  "grinders' 
consumption  "  whose  average  Hfe  was  twelve  years. 

Treatment.  To  prevent  the  hyperplasia  of  the  connective  tissue, 
hydrargvri  coyrosivin)i  ch/oriduni,  potassii  iodidmn  or  aurii  et  sodii 
chloridum,  are  recommended.      Oleum  inorrhiicc  is  of  benefit. 

The  bronchial  catarrh,  hectic  fever  and  7iight  sweats  should  be 
treated  onlv  when  their  severitv  becomes  marked. 


ACUTE  PHTHISIS. 

Sjmonyms.     Acute  miliary  tuberculosis  ;  galloping  consumption. 

Definition.  An  acute  febrile  affection,  due  to  the  rapid  deposition 
throughout  the  body,  but  especially  in  the  lungs,  of  the  gray  tubercle- 
granule;  characterized  by  high  fever,  rapid  pulse,  hurried  respiration, 
pain  in  the  chest,  cough,  profuse  expectoration  and  rapid  prostration. 

Causes.     Most  common  between  puberty  and  middle  life. 

"That  the  gray  granulation  is  deposited  throughout  the  body  under 
the  influence  of  certain  conditions  of  irritation,  it  is  necessary  that  a 
peculiar  vulnerability  of  the  constitution  exist,  in  other  words,  that  it 
be  of  the  scrofulous  type." 

The  result  of  caseous  or  suppurative  changes  in  the  lungs. 

Pathological  Anatomy.  "  The  gray  granulation  or  miliary 
tubercle  consists  of  a  fine  reticulation  of  fibres,  with  a  mass  of  epi- 
thelioid cells  and  granules,  and  often  having  a  giant  cell  for  its 
centre." 

The  deposit  is  generally  over  both  lungs  and  the  bronchial  tubes, 
and  is  followed  by  hyperaemia,  increase  of  secretion,  having  a  viscid 
and  adhesive  character,  and  the  destruction  of  all  the  tissue  with 
which  it  comes  in  contact. 

Deposits  also  take  place  in  the  brain,  pleura,  intestines,  peritoneum 
and  kidneys. 

Symptoms.  The  onset  is  usually  sudden,  with  a  chill  or  chilli- 
ness;, followed  by  fever,  J02'^-i04°  F.,  rapid,  d'xcroUc  />ulse,  120-140, 
cough,  with  scanty,  glairy  sputum,  increased  respiration,  30-50  per 
minute,/^/;/  in  the  chest,  hot  skin,  dry  tongue,  deranged  digestion 
and  great  prostration,  the  severity  of  the  symptoms  rapidly  increasing, 
the  sputum  becoming  more  abundant  and  often  rusty  in  color,  with 
more  or  less  frequent  attacks  of  hcEinoptysis,  soon  followed  by  head- 
ache, vertigo,  sleeplessness,  often  delirium,  coma  and  death. 


DISEASES   OF   THE   PLEURA.  261 

If  deposits  have  occurred  in  the  meninges  or  the  intestines,  symp- 
toms of  these  affections  are  superadded. 

Percussion.  The  percussion  resonance  is  normal  until  consider- 
able deposits  have  occurred,  when  it  is  either  slightly  impaired  or  even 
slightly  tympanitic.  With  the  development  of  cavities  the  amphoric 
percussion  note  is  present. 

Auscultation.  Vesiculo-bronchial  breathing,  associated  with 
large  and  small,  moist  or  bubbling  rales,  soon  followed  by  bronchial 
and  broncho-cavernous  breathing,  with  large  and  small,  moist  and 
circumscribed  gurgling  rales. 

Duration.  Acute  phthisis  terminates  fatally  in  from  four  to 
twelve  weeks. 

Diagfnosis.  Commonly  mistaken  for  typhoid  fever  with  lung 
complications,  an  error  that  is  readily  made  unless  a  close  study  of 
the  history,  symptoms  and  physical  signs  be  made. 

Treatment.  There  are  no  means  of  retarding  the  progress  of 
this  malady.  Loomis  says:  "  Morphia  in  small  doses — one-twentieth 
of  a  grain  hypodermically  every  six  or  eight  hours — has,  in  my  hands, 
been  more  satisfactory  in  staying  the  progress  of  the  disease,  pro- 
longing life,  and  keeping  the  patient  comfortable,  than  any  other 
plan." 

Dr.  McCall  Anderson  claims  that  subcutaneous  injections  of  atro- 
pina  check  the  exhausting  sweats ;  and  that  quinina,  digitalis  and 
opium  reduce  the  temperature,  and  if  they  fail,  ice  cloths  to  the  abdo- 
men will  accomplish  the  desired  result. 

The  various  symptoms  should  be  met  as  they  occur,  the  patient  at 
the  same  time  being  supplied  with  large  quantities  of  sti7nula7its. 


DISEASES  OF  THE  PLEURA. 


PLEURISY. 

Synonyms.     Pleuritis;    "stitch  in  the  side." 

Definition.  A  fibrinous  inflammation  of  the  pleura,  either  acute, 
subacute  or  chronic  in  character,  occurring  either  idiopathically  or 
secondarily;  characterized  by  a  sharp  pain  in  the  side,  a  dry  cough. 


262  PRACTICE   OF   MEDICINE. 

dyspnoea  and  fever.     It  may  be  limited  to  a  part,  or  may  involve  the 
whole  of  one  or  both  membranes. 

Causes.  Idiopathic  pleuritis  is  said  to  be  due  to  cold  and  expo- 
sure, to  injuries  of  the  chest  walls,  or  the  result  of  muscular  exertion. 

Secondary  pleuritis  occurs  during  an  attack  of  pneumonia,  peri- 
carditis, rheumatism,  smallpox,  Bright's  disease,  or  puerperal  fever. 

Chronic  pleurisy  follows  an  acute  attack,  or  is  the  result  of  tuber- 
culosis, Bright's  disease,  or  alcoholism. 

Pathological  Anatomy.  The  course  pursued  by  an  inflam- 
mation of  a  serous  membrane  is  JiypercE)nia  followed  by  exudation  of 
lymph,  the  effusio)i  of  fluid,  its  absorption  and  the  adhesion  of  the 
membranes. 

The  first  or  dry  stage  of  pleurisy  is  hyperaemia  or  diffused,  irreg- 
ular redness  of  the  membrane,  with  little  specks  of  exudation.  The 
second  stage  is  characterized  by  the  copious  exudation  of  lymph,  more 
or  less  completely  covering  the  membrane,  giving  it  a  dull,  cloudy, 
or  shaggy  appearance.  If  the  inflammation  ceases  at  this  point,  it  is 
termed  dry  pleurisy.  The  third,  or  stage  of  effusion,  is  characterized 
by  the  pouring  out  of  a  semi-fibrinous  liquid  ;  more  or  less  completely 
filling  and  distending  the  pleural  cavity,  and  floating  in  the  fluid  are 
fibrinous  flocculi,  blood  and  epithelial  cells. 

Absorption  of  the  fluid  and  more  or  less  of  the  exudative  lymph 
soon  occurs,  the  unabsorbed  portion  becoming  organized,  forming 
adhesions  which  obliterate  the  pleural  cavity. 

The  effusion,  if  on  the  right  side,  pushes  the  heart  further  to  the 
left ;  if  on  the  left  side,  the  heart  is  displaced  to  the  right,  the  impulse 
often  being  seen  to  the  right  of  the  sternum.  The  lungs  are  also 
compressed  and  displaced  upward  and  against  the  spinal  column, 
and,  on  removal  of  the  fluid,  expand  again,  except  in  cases  of  chronic 
pleurisy,  when  the  functional  activity  of  the  pulmonary  structure  is 
more  or  less  permanently  impaired. 

Chronic  pleurisy  results  when  the  fluid  is  not  absorbed  or  when  it  is 
effused  into  the  cavity  in  a  slow  and  insidious  manner.  The  mem- 
brane is  irregularly  thickened,  with  firm  adhesions,  fluid  being  found 
in  the  meshes,  and  depressions  of  the  thoracic  walls  also  occurring. 
The  fluid  may  be  serum,  pus  {empyema),  or  pus  and  blood.  Openings 
may  form,  through  which  there  is  a  permanent  discharge,  either  ex- 
ternally (fistulous  empyema)  or  into  the  bronchi,  or  rarely,  into  the 
bowels. 


DISEASES    OF   THE   PLEURA,  263 

Symptoms.  Acute  attack :  Begins  with  a  chill,  followed  by  a 
sharp  lancinating ^«z>?  (stitch)  near  the  nipple  or  in  the  axilla,  aggra- 
vated by  coughing  and  breathing,  associated  with  slight  tenderjicss  on 
pressure.  The  respirations  are  rapid  and  shallow,  30-35  per  minute, 
a  short,  dry,  hacking  cough,  moderate  fever,  compressible  pulse,  90- 
120.  With  the  effusion  of  liquid  the  dyspnosa  becomes  aggravated, 
the  cough  more  distressing,  the  cardiac  action  embarrassed,  the  coun- 
tenaiice  wearing  an  anxious  expression,  the  patient  usually  lying  on 
the  affected  side.  With  the  absorption  of  the  fluid  the  symptoms 
gradually  ameliorate,  convalescence  being  more  or  less  rapid. 

Subacute  attack :  Begins  insidiously  after  cold,  exposure  and 
fatigue  in  those  enfeebled.  Patients  usually  complain  of  a  sense  of 
weariness,  shortness  of  breath,  aggravated  on  exertion,  evening y^z/^r, 
followed  by  night  sweats,  short,  harassing  cough,  none  or  very  scanty 
sputum  ;  the  pulse  is  small,  feeble  but  frequent,  100-120  beats  per 
minute.     The  characteristic  pain  in  the  side  is  usually  wanting. 

Chronic  variety,  irregular  chills,  fever,  night  sweats,  dyspnoea, 
palpitation,  embarrassed  circulation,  with  more  or  less  prostration. 

Inspection.  First  stage,  deficient  movement  of  the  affected  side, 
on  account  of  the  pain  induced  by  full  breathing. 

Second  stage,  bulging  or  fullness  of  the  affected  side,  with  oblitera- 
tion of  the  intercostal  spaces  and  displacement  of  the  cardiac  impulse. 

Palpation.  Second  stage,  vocal  frejnitus  feeble  or  absent  over 
the  site  of  the  effusion,  exaggerated  above  the  site  of  the  fluid. 
'R.2iYQ[y , fluctuation  may  be  obtained. 

Percussion.     First  stages,  may  be  slightly  impaired. 

Second  stage,  dullness  or  even  flatness  over  the  site  of  the  effusion  ; 
tympanitic  percussion  note  above  the  fluid. 

Auscultation.  First  stage,  feeble  vesicular  murmur  over  the 
affected  side,  the  patient  breathing  superficially,  to  prevent  the  pain  ; 
?L  friction  sound,  slight  and  grating  or  creaking,  becoming  louder  as 
the  exudation  of  lymph  increases,  limited  usually  to  the  angle  of  the 
scapula  of  the  aft'ected  side,  rarely  heard  over  the  entire  side,  accom- 
panies the  respiratory  movements. 

Second  stage,  feeble  or  absent  vesicular  murmur  on  the  affected 
side,  depending  upon  partial  or  complete  compression  of  the  lungs  by 
the  fluid.  Above  the  fluid  puerile  breathing,  and  iust  at  the  upper 
margin  of  the  fluid  a  friction  sound  may  be  heard. 

The  vocal  resonance  is  diminished  or  absent  over  the  site  of  the 


264  PRACTICE   OF   MEDICINE. 

fluid  and  markedly  increased  above,  CEgophony  being  present  at  the 
upper  margin  of  the  fluid. 

With  the  absorption  of  the  fluid  the  vesicuhir  murmur  gradually 
returns,  associated  with  a  moist  friction  sound. 

Diag'nosis.  Acute  pneumonia  is  often  mistaken  for  the  effusion 
stage  of  pleurisy.  The  points  of  distinction  are,  in  pneumonia  there 
is  the  pronounced  chill,  high  fever,  and  characteristic  sputa,  bronchial 
breathing,  exaggerated  vocal  fremitus  and  resonance,  and  no  dis- 
placement of  the  heart,  the  reverse  occurring  in  pleurisy. 

Enlargement  of  the  liver  may  be  mistaken  for  pleurisy  with  effusion, 
the  chief  point  of  distinction  being  that,  in  enlargement  of  the  liver, 
the  superior  line  of  dullness  is  depressed  upon  full  inspiration,  while 
in  pleurisy  with  effusion  inspiration  does  not  modify  the  location  of 
the  dullness, 

Prog'nosis.  Idiopathic  pleurisy  usually  terminates  in  recovery 
within  three  weeks.  Pleurisy  the  result  of  constitutional  causes  has 
its  prognosis  modified  by  the  condition  with  which  it  is  associated. 
Etnpyema,  unless  the  result  of  a  diathesis,  terminates  favorably. 
Double  pleurisy  is  imfavorable. 

Treatment.  At  the  onset,  in  plethoric  patients,  wet  cups  over  the 
affected  side  ;  if  great  dyspnoea,  severe  pain  and  high  arterial  tension, 
even  venesection,  and  in  anaenic  or  weak  persons,  dry  cups,  follow- 
ing the  use  of  either  wet  or  dry  cups  with  poultices  or  turpentine 
stupes.  The  severe  pain  is  promptly  relieved  by  the  hypodermic  in- 
jection of  morpJmice  sulphas  over  its  site,  repeated  as  indicated,  or 
the  frequent  use  of  small  doses  o^ pulvis  opii  et  ipecacuanh(Z. 

Tinct.  verat.  virid.,  or  tinctura  aconiti,  in  small  doses,  frequently 
repeated,  in  the  plethoric,  and  digitalis  in  the  weak,  control  the  circu- 
lation, and  lessen  the  amount  of  blood  distributed  to  the  affected 
membrane. 

After  effusion  has  begun,  extractum  pilocarpi  fiuidum,  gtt.  xx, 
every  two  or  three  hours,  or  in  drachm  doses  every  other  day  for  a 
week  or  two,  after  which  twice  weekly,  or — 

U  •     Potassii  acetat., gr.  xxx 

Ir)fus.  digitalis,       ^ij.  M. 

Every  ihree  or  four  hours. 

If  the  effusion  be  uninfluenced  by  the  above,  usq  potassii  iodidum, 
gr.  XV,  every  four  hours,  with  flying  blisters  over  the  affected  side ;  -or 


DISEASES   OF  THE   PLEURA.  265 

the  fluid  may  be  evacuated  by  aspiration,  using  at  the  same  time 
full  doses  of  mistura  ferri et  amvionii  acetatis  {Basham's  mixture). 
Locally  in  the  arm-pits,  groins,  or  over  the  site  of  the  effusion,  tm- 
guentum  hydrargyri. 

The  effusion  of  pleuritis  is  rapidly  removed  by  the  method  of  treat- 
ment suggested  by  Prof.  Matthew  Hay,  of  Scotland,  consisting  in  the 
use  of  a  concentrated  solution  of  saline  cathartics  :  "  order  the  patient 
to  take  nothing  after  the  evening  meal,  and  then,  an  hour  or  so  before 
breakfast,  the  salt  is  given  dissolved  in  as  little  water  as  possible. 
Usual  dose  from  5iv-vj  to  ^j-ij  magnesii  sulphatis  to  an  ounce  or 
two  of  water,  no  fluids  to  be  used  after  the  dose  ;  this  usually  produces 
from  four  to  eight  watery  stools  without  pain  or  discomfort  and  also 
acts  as  a  diuretic." 

The  essence  of  the  "  Hay  method  "  consists  in  getting  the  concen- 
trated solution  into  the  intestines  at  a  time  when  the  fluid  contents 
are  scanty. 

If  double  pleuritic  effusion,  evacuate  the  fluid  at  once  with  the  aspi- 
rator, and  use  the  potassium  and  digitalis  mixture  mentioned  above. 

Chronic  pleurisy  :  if  the  effusion  be  still  serous,  it  is  often  absorbed 
by  the  internal  use  oi  potassii  iodidum,  alternating  with  "  B  as  ham's 
mixture,'"  and  blisters,  the  secretions  being  regularly  attended  to.  If, 
however,  the  liquid  is  pus  {empyema),  the  aspirator  should  be  used  at 
once,  the  patient  placed  upon  "  Basham's  mixture,''  stimulants  and 
quinina. 

Usually,  however,  within  a  very  few  days  after  aspiration,  another 
accumulation  of  pus  will  have  taken  place.  Should  this  occur,  the 
purulent  pleurisy  should  then  be  treated  as  an  abscess,  an  incision 
being  made  between  the  fifth  and  sixth  ribs,  the  pus  evacuated,  a 
drainage  tube  introduced  and  an  antiseptic  dressing  applied.  If  the 
tendency  to  pus  secretion  still  remains  the  pleural  cavity  must  be 
washed  out  with  an  antiseptic  solution,  the  constitutional  treatment 
being  continued. 

HYDROTHORAX. 

Synonym.     Dropsy  of  the  pleura. 

Definition.  The  effusion  of  fluid  into  the  pleural  cavities  (bilat- 
eral), the  result  of  a  general  dropsy  from  renal  or  cardiac  disease. 

Pathological  Anatomy.  More  or  less  clear  serous  fluid  in 
both  pleural  sacs,  compressing  the  lungs.  No  signs  of  inflammation 
are  present. 

22 


266  PRACTICE   OF   MEDICINE. 

Symptoms.  Following  dropsy  of  the  abdomen  occurs  dyspnoea, 
with  signs  of  deficient  blood  aeration,  both  lungs  being  compressed. 

Palpation.     Absent  vocal  fremitus  over  the  site  of  the  fluid. 

Percussion.     Dullness  over  the  site  of  the  fluid. 

Auscultation.  Absent  vesicular  murmur  over  the  site  of  the 
fluid. 

Diagnosis.  Easily  determined  by  association  of  the  symptoms 
with  a  general  dropsy. 

Prognosis.  Controlled  by  the  cause  producing  the  general 
dropsy. 

Treatment.  Depending  upon  the  condition  causing  the  dropsy. 
Dry  cups  over  the  chest  afford  relief.  If  the  symptoms  of  non-aera- 
tion of  the  blood  are  severe,  the  fluid  should  be  at  once  evacuated 
with  the  aspirator. 

PNEUMOTHORAX. 

Synonyms.     Air  in  the  pleural  cavity  ;  hydropneumothorax. 

Definition.  The  accumulation  of  air  in  the  pleural  cavities,  with 
the  consequent  development  of  inflammation  of  the  membranes; 
characterized  by  sharp  pain,  followed  by  rapidly  developing  dyspnoea 
and  cough. 

Causes.  Generally  the  result  of  tubercular  phthisis,  causing  per- 
foration of  the  pleura.  Perforation  may  take  place  from  the  pleura 
into  the  lung,  in  connection  with  empyema  or  abscess  of  the  chest 
walls.  Direct  perforation  from  without,  by  laceration  of  fractured 
rib  or  severe  contusion. 

Pathological  Anatomy.  The  gas  in  the  pleural  cavity  consists 
of  oxygen,  carbon  anhydride,  and  nitrogen  in  variable  proportions. 
It  may  fill  the  pleural  sac  completely,  compressing  the  lung,  or  is 
sometimes  limited  by  adhesions.  The  gas  tends  to  excite  inflamma- 
tion, the  resulting  effusion  being  either  serous  or  purulent. 

Symptoms.  Symptoms  of  pneumothorax,  the  result  of  perfora- 
tion, are  sudden  or  sharp  pain  in  the  side,  intense  dyspnoea,  attended 
with  symptoms  of  collapse,  coldness  of  the  surface  and  cold  sweats. 

The  above  symptoms,  in  many  instances,  follow  a  severe  or  violent 
"p^xox^svcy  o{ coughing.  In  severe  cases  there  is  never  a  moment's 
cessation  of  the  acute  pain  and  distressing  dyspnoea,  causing  orthop- 
ncea  from  the  onset  until  death. 


DISEASES   OF   THE   PLEURA.  267 

Inspection.  Enlargement  of  the  affected  side,  the  intercostal 
spaces  being  widened  and  effaced,  or  even  bulged  out  so  that  the 
surface  of  the  chest  is  smooth.  Respiratory  movements  of  the  affected 
side  are  diminished  or  absent. 

Percussion.  Immediately  after  the  rupture  the  percussion  note 
is  hyper-resonant,  or  even  tympanitic  or  amphoric  in  quality.  If  the 
amount  of  air  in  the  pleural  cavity  becomes  extreme  there  is  dullness 
on  percussion,  associated  with  a  feeling  of  great  resistance  or  density. 
When  effusion  of  blood  occurs  dullness  is  observed  over  the  lower 
part  of  the  chest,  hyper-resonant  or  tympanitic  percussion  note  over 
the  upper  portions  of  the  chest,  these  sounds  changing  as  the  patient 
changes  his  position. 

Auscultation.  The  normal  vesicular  murmur  may  be  diminished 
or  absent.  The  typical  amphoric  respiratory  sound  is  heard  when 
the  fistula  is  open,  usually  associated  with  a  metallic  echo. 

Metallic  tinkling,  or  the  bell  sound,  is  sometimes  distinctly  pro- 
duced by  breathing,  coughing  or  speaking,  after  the  development  of 
inflammation  of  the  pleura. 

The  vocal  resonance  may  be  diminished  or  absent,  or,  rarely,  it 
may  be  exaggerated,  with  a  distinct  metallic  echo. 

After  the  development  of  inflammation  in  the  pleura,  suddenly 
shaking  the  patient  gives  rise  to  a  splashing  seiisation,  the  succussion 
sound,  if  both  air  and  fluid  are  present  in  the  pleural  cavity. 

Prognosis.  When  occurring  as  the  result  of  tuberculosis,  the 
prognosis  is  extremely  unfavorable;  rarely,  the  fistulous  opening 
being  closed  by  inflammatory  action  ;  the  case  then  becomes  one  of 
chronic  pleurisy. 

Treatment.  At  once  a  hypodermic  injection-  of  morphincE 
sulphas,  which  relieves  the  severe  pain  and  somewhat  modifies  the 
distressing  dyspnoea,  followed  by  the  evacuation  of  the  fluid  and  air 
with  the  aspirator. 

If  the  fistulous  opening  be  closed  by  inflammatory  action,  the  case 
resolves  itself  into  one  of  chronic  pleurisy,  the  treatment  indicated  for 
that  affection  plus  the  treatment  of  tuberculosis,  being  tl^e  indication. 


268  PRACTICE   OF   MEDICINE. 

DISEASES    OF   THE   CIRCULATORY 
SYSTEM. 


The  methods  employed  in  making  a  physical  examination  of  the 
heart  are  :  I.  Inspection.  II.  Palpation.  III.  Percussion.  IV.  Aus- 
cultation. 

Inspection  indicates  the  exact  point  of  the  cardiac  iinfiulse, 
and  whether  there  be  any  abnormal  pulsations  or  any  c/iafige  in  the 
form  of  prcECordium. 

Normally  the  impulse  is  visible  only  in  \hejifth  interspace,  midway 
between  the  left  nipple  and  the  left  border  of  the  sternum,  its  area 
covering  about  one  square  inch,  most  distinct  in  the  thin,  wdiile  often 
barely  seen  in  the  very  fleshy  ;  often  displaced  downward  by  full  in- 
spiration and  elevated  by  complete  expiration. 

Disease  may  alter  the  position  and  area  of  the  impulse. 

The  position  of  the  impulse  is  moved  to  the  right  by  left  pleuritic 

effusions ;    downward   by  hypertrophy  or   emphysema ;    upward  by 

pericardial  effusion. 

The  area  of  the  impulse  is  changed  and  enlarged  by  pericardial 

adhesions,  cardiac  dilatation,  or  hypertrophy. 

Palpation  confirms  the  observations  of  inspection,  and  also  deter- 
mines the  force,  frequency  and  regularity  of  the  cardiac  ijnpulse. 

The  impulse  is  dijninished  by  cardiac  dilatation,  fatty  degenera- 
tion of  the  heart,  emphysema,  pericardial  effusion,  and  adynamic 
disease. 

The  impulse  is  increased  by  cardiac  hypertrophy,  during  the  first 
stage  of  endocarditis  and  pericarditis,  functional  cardiac  disturbances 
and  sthenic  inflammations. 

Percussion  will  indicate  the  boundaries  of  the  superficial  and 
deep  cardiac  space,  the  so-called  prcEcordium.  It  is  essential  that  the 
upper,  lower,  and  two  lateral  boundaries  of  the  pericardial  region  be 
memorized,  to  wit :  superior  boundary,  the  upper  edge  of  the  third 
rib  ;  the  lower  boundary  is  a  horizontal  line  passing  through  the  fifth 
intercostal  space;  the  left  lateral  boundary  is  about  or  a  little  within 
a  vertical  line  passing  through  the  nipple,  the  li7iea  ma^nmalis ;  and 
the  right  lateral  boundary  is  an  imaginary  vertical  line  situated  one- 
half  an  inch  to  the  right  of  the  sternum.     These  boundaries  vary 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  269 

somewhat  in   health,  but   are  sufficiently  accurate  for   all  practical 
purposes. 

The  superficial  cardiac  space  represents  that  portion  of  the  heart 
uncovered  with  lung ;  it  is  triangular  in  form,  its  apex  being  the  junc- 
tion of  the  lower  border  of  the  left  third  rib  with  the  sternum,  its 
area  not  exceeding  two  inches  in  any  direction. 

The  superficial  space  is  increased  by  cardiac  hypertrophy,  dilatation 
or  pericardial  effusion. 

Diminished  at  the  end  of  full  inspiration  or  by  emphysema. 

The  deep  cardiac  space  represents  that  portion  of  the  heart  covered 
by  lung,  and  extends  from  the  upper  border  of  the  third  rib  to  the 
lower  edge  of  the  fifth  interspace,  and  from  half  an  inch  to  the  right 
of  the  sternum  to  near  the  left  nipple. 

It  is  increased  by  hypertrophy  or  dilatation  of  the  heart,  left  pleuritic 
effusion,  and  apparently  increased  by  consolidation  of  the  anterior 
border  of  the  investing  lung. 

Auscultation  indicates  the  character  of  the  normal  cardiac 
sounds  and  the  point  of  greatest  intensity  at  which  they  are  heard, 
and  should  be  thoroughly  familiarized  if  abnormal  sounds  are  to  be 
fully  appreciated. 

The  ear  or  stethoscope  applied  to  the  prsecordium  distinguishes  two 
sounds,  separated  by  a  momentary  silence — the  short  pause,  and  the 
second  sound  followed  by  an  interval  of  silence — the  long patise. 

The  first  sound,  corresponding  to  the  contraction  of  the  heart — the 
systole — is  louder,  longer  and  of  lower  pitch  and  a  more  booming 
quality  than  the  second  sound,  and  has  its  point  of  greatest  intensity 
at  the  cardiac  apex  or  a  little  to  the  left.  It  corresponds  closely  to  the 
pulsations  as  felt  in  the  carotid  or  radial  arteries. 

The  second  sound  is  shorter,  weaker  and  higher  in  pitch  than  the 
first  sound,  and  has  a  clicking  or  valvular  quality,  having  its  point  of 
greatest  intensity  at  the  second  right  costal  cartilage  and  a  little 
above,  and  corresponds  to  the  closure  of  the  aortic  and  pulmonary 
valves.  The  sound  made  by  the  closure  of  the  tricuspid  valves  is 
best  isolated  at  the  ensiform  cartilage.  The  sound  made  by  the 
closure  of  the  pulmonary  valves  at  the  third  left  costal  cartilage. 

The  extent  of  surface  over  which  the  cardiac  sounds  are  heard 
varies  according  to  the  size  of  the  heart  and  the  condition  of  the 
adjacent  organs  for  transmitting  sounds. 

The  cardiac  sounds  may  be  altered  in  intensity,  quality,  pitch,  seat 


27U  PRACTICE   OF   MEDICINE. 

and  rhythm,  or  they  may  be  accompanied,  preceded  or  followed  by 
adventitious  or  new  sounds,  the  so-called  endocardial  miirmurs. 

The  intensity  is  increased  by  cardiac  hypertrophy,  irritability  of  the 
heart  or  consolidation  of  adjacent  lung  structure. 

The  intensity  is  diminished  by  cardiac  dilatation  or  degeneration, 
during  the  course  of  adynamic  fevers,  emphysematous  lung  overlap- 
ping the  heart,  or  pericardial  effusion. 

The  quality  and  pitch  of  the  first  sound  may  be  sharp  or  short 
and  of  higher  pitch  when  the  ventricular  walls  are  thin,  the  valves 
being  normal  ;  its  pitch  and  quality  are  also  raised  during  the  course 
of  low  fevers.  The  second  sound  becomes  duller  and  lower  in  pitch 
when  the  elasticity  of  the  aorta  is  diminished  or  the  aortic  valves 
thickened.  Either  or  both  sounds  have  a  more  or  less  metallic  qual- 
ity in  irritable  heart  and  during  gaseous  distention  of  the  stomach. 

The  seat  of  greatest  intensity  o{  the  cardiac  sound  is  changed  by 
displacement  of  the  heart,  pleuritic  effusion,  pericardial  effusion,  and 
abdominal  tympanites. 

The  rhythm  is  often  interrupted  by  a  sudden  pause  or  silence,  the 
heart  missing  a  beat,  or  the  sounds  are  irregular,  confused  and  tumul- 
tuous, the  result  of  organic  changes  in  the  cardiac  muscles,  valves, 
or  orifices ;  or  a  reduplication  of  one  or  both  sounds  of  the  heart  may 
occur. 

The  adventitious  cardiac  sounds  or  jnurmurs  are  of  two  kinds,  those 
made  external  to  the  heart,  as  pericardial,  exocardial  or  frictional 
murmurs,  and  those  made  within  the  cardiac  cavity,  endocardial 
7nurmurs. 

Pericardial  murmurs,  or  friction  sounds,  are  made  by  the  rubbing 
upon  one  another  of  the  roughened  surfaces  of  the  pericardial  mem- 
brane during  the  early  stages  of  inflammation.  The  sounds  have  a 
rubbing,  creaking,  or  grating  character,  and  are  differentiated  from  a 
pleural  friction  sound  by  their  being  limited  to  the  praecordium,  syn- 
chronous with  every  sound  of  the  heart,  and  not  influenced  by  respi- 
ration. 

They  are  distinguished  from  an  endocardial  murmur  by  their  super- 
ficial rubbing,  creaking  or  grating  character,  and  by  not  being  trans- 
mitted beyond  the  limits  of  the  heart,  either  along  the  course  of  the 
vessels,  or  to  the  left  axilla,  or  back. 

Endocardial  murtnurs  are  of  two  kinds,  to  wit :  organic  and  func- 
tional. 


DISEASES  OF  THE   CIRCULATORY  SYSTEM.  271 

Functional  endocardial  OX  blood  murmurs  are  the  result  of  changes 
in  the  natural  constituents  of  the  blood. 

Their  character  is  soft,  they  are  heard  most  distinctly  at  the  base  to 
the  left  of  the  sternum,  during  the  systole,  and  not  transmitted  beyond 
the  limits  of  the  heart,  either  to  the  left  axilla  or  the  back,  and  are 
associated  with  general  anaemia. 

Organic  endocardial  murmurs  are  produced  by  blood  currents 
pursuing  either  a  normal  or  an  abnormal  direction. 

In  health  there  are  two  direct  blood  currents  upon  each  side  of  the 
heart,  to  wit :  the  current  from  the  left  auricle  to  the  left  ventricle,  the 
mitral  direct  currefit ;  the  current  from  the  left  ventricle  to  the  aorta, 
the  aortic  direct  current ;  the  current  from  the  right  auricle  to  the  right 
ventricle,  the  tricuspid  direct  current,  and  the  current  from  the  right 
ventricle  to  the  pulmonary  artery,  the  pulmonic  direct  current. 

When,  from  disease,  the  valves  are  not  properly  closed,  the  blood 
is  allowed  to  flow  back  against  the  direct  current,  producing  abnormal 
blood  currents,  to  v/it:  when  the  mitral  valve  is  incompetent,  the 
blood  flows  from  the  left  ventricle  back  to  the  left  auricle  during  the 
cardiac  systole,  producing  the  mitral  regurgitant  or  indirect  current  ; 
when  the  aortic  valves  are  incompetent,  the  blood  is  permitted  to 
flow  from  the  aorta  into  the  left  ventricle  during  the  cardiac  systole, 
producing  the  aortic  regurgitant  or  indirect  current ;  when  the 
tricuspid  valves  are  incompetent,  the  blood  flows  from  the  right 
ventricle  back  into  the  right  auricle  during  the  systole,  producing 
the  tricuspid  regurgitant  or  indirect  current;  when  the  pulmonary 
valves  are  incompetent,  the  blood  flows  from  the  pulmonary  artery 
into  the  right  ventricle,  producing  the  pulmonic  regurgitant  or  indirect 
current. 

The  mitral  direct  current  occurs  during  the  contraction  of  the  left 
auricle,  or  just  before  the  first  sound  of  the  heart  and  immediately 
after  its  second  sound.  The  aortic  direct  current  is  produced  by  the 
contraction  of  the  left  ventricle,  and  occurs  with  the  first  sound  of  the 
heart.  The  tricuspid  direct  curroit  occurs  during  the  contraction  of 
the  right  auricle,  or  just  before  the  first  or  immediately  after  the  second 
sound.  The  pulmonic  direct  current  is  produced  by  the  contraction 
of  the  heart,  occurring  during  its  first  sound. 

The  mitral  direct,  or  presystolic  murmur,  occurs  before  the  first 
sound  of  the  heart  and  immediately  after  the  second  sound.  It  is 
caused  by  a  narrowing  of  the  mitral  orifice,  has  a  blubbering  quality, 


272  PRACTICE  OF   MEDICINE. 

well  imitated  by  throwing  the  lips  into  vibration  by  the  breath,  of  a 
low  pitch,  and  it  has  its  seat  of  greatest  intensity  at  the  cardiac  apex, 
and  is  not  transmitted  to  the  left  axilla  or  to  the  base  of  the  heart. 

The  mitral  regurgitant,  or  systolic  murfnur,  occurs  with  the  first 
sound  of  the  heart,  resulting  from  the  failure  of  the  mitral  valves  to 
close  the  mitral  orifice  during  the  systole,  in  consequence  of  which 
the  blood  flows  back,  or  regurgitates  into  the  left  auricle.  It  is  usually 
of  a  blowing  or  churning  character,  and  has  its  seat  of  greatest  in- 
tensity at  the  cardiac  apex,  being  well  transmitted  to  the  left  axilla 
and  inferior  angle  of  the  left  scapula. 

The  aortic  direct  murmur  occurs  with  the  second  sound  of  the  heart. 
It  is  caused  by  a  narrowing  of  the  aortic  orifice,  has  a  rough  or  creak- 
ing character,  is  of  high  pitch,  having  its  seat  of  greatest  intensity  in 
the  second  intercostal  space,  to  the  right  of  the  sternum,  and  is  well 
transmitted  over  the  carotid  artery. 

The  aortic  res^iirsritant  murmur  occurs  with  the  second  sound  of  the 
heart,  and  is  caused  by  the  failure  of  the  aortic  valves  to  close  the 
aortic  orifice  during  the  diastole,  whereby  the  blood  flows  back  or 
regurgitates  into  the  left  ventricle.  It  is  usually  of  a  blowing  or 
churning  character  and  of  low  pitch,  having  its  seat  of  greatest  in- 
tensity over  the  base  of  the  heart,  and  is  well  transmitted  downward 
toward  or  below  the  cardiac  apex.  It  is  the  only  organic  murmur 
produced  in  the  left  side  of  the  heart  which  occurs  with  the  second 
sound  of  the  heart. 

The  tricuspid  direct  murmur  occurs  before  the  first  sound  of  the 
heart  and  immediately  after  the  second  sound.  It  is  caused  by  a  nar- 
rowing of  the  tricuspid  orifice,  has  a  blubbering  quality,  and  is  low 
in  pitch,  having  its  seat  of  greatest  intensity  near  the  ensiform  car- 
tilage.    This  murmur  is  exceedingly  rare. 

The  tricuspid  regurgitant  murmur  occurs  with  the  first  sound  of 
the  heart,  the  result  of  the  failure  of  the  tricuspid  valves  to  close  the 
tricuspid  orifice  during  the  systole,  thus  allowing  the  blood  to  flow 
back  or  regurgitate  into  the  right  auricle.  It  is  usually  of  a  blowing, 
or  soft,  churning  character,  having  its  seat  of  greatest  intensity  at  the 
ensiform  cartilage.  This  murmur  is  also  very  infrequent,  and  occurs 
mostly  when  the  right  ventricle  is  considerably  dilated,  without  the 
existence  of  any  valvular  disease. 

The  pulmonic  direct  7mtrmur  occurs  with  the  first  sound  of  the 
heart.     It  is  generally  connected  with  congenital  lesions.  It  occurs 


DISEASES   OF   THE   CIRCULATORY  SYSTEM.  273 

at  the  same  instant  that  the  aortic  direct  murmur  occurs,  and  is  dis- 
tinguished from  the  latter  by  its  not  being  transmitted  into  the  carotid 
artery,  whereas  the  aortic  direct  murmur  is  always  thus  transmitted. 

The  pidmonic  regurgitant  muriniir  occurs,  like  the  aortic  regurgi- 
tant murmur,  with  the  second  sound  of  the  heart.  This  murmur  is 
exceedingly  rare,  and  its  presence  is  only  positively  differentiated 
from  the  aortic  regurgitant  murmur  by  the  absence  of  aortic  lesions 
and  symptoms. 

ACUTE  PERICARDITIS. 

Definition.  An  acute  hbrinous  inflammation  of  the  pericardium  ; 
characterized  by  slight  fever,  pain,  prsecordial  distress  and  disturbed 
cardiac  action  and  circulation. 

If  the  inflammation  be  limited  to  the  parietal  or  visceral  layer,  or 
to  a  part  of  either,  it  is  termed  partial  or  circuinscribed  pericarditis  ; 
if  it  involve  the  whole  of  both  surfaces  it  is  termed  general  or  diffused 
pericarditis. 

Causes.  May  follow  injuries  of  the  chest  walls,  or  be  the  result 
of  taking  cold,  but  generally  secondary  to  either  acute  articular  rheu- 
matism, pneumonia,  pleurisy,  erysipelas,  Bright's  disease  or  pyaemia. 

Path.olog"ical  Anatomy.  The  same  as  serous  membranes  in 
other  situations, 

Hyper(E7tiia  of  the  membrane,  most  marked  on  the  visceral  layer, 
followed  by  the  exudation  of  lymph  scattered  in  irregular  patches, 
giving  it  a  rough  and  shaggy  appearance  {dry  pericarditis),  followed 
by  the  effusion  of  a  sero-fibrinous  fluid,  with  flocculi  floating  on  it,  and 
at  times  mixed  with  blood.     Rarely,  the  fluid  is  purulent. 

The  fluid  and  lymph  undergo  absorption  with  resulting  adhesions 
identical  with  those  described  under  pleurisy. 

Symptoms.  Acute  pericarditis  may  be  well  marked  and  still 
present  none  of  the  characteristic  subjective  symptoms.  It  usually 
begins  with  rigors,  fever  of  the  remittent  type,  frequently  nausea 
and  •vovcnimg,  prcEcordial  distress,  acute  shooting  paints,  increased  by 
breathing  and  coughing,  tenderness,  dry,  suppressed  cough,  increased 
cardiac  actio7i,  and  sometimes  violent  palpitation.  An  attack  of  peri- 
carditis secondary  to  an  existing  disease  presents  no  marked  symp- 
toms other  than  those  mentioned  to  indicate  its  onset.  Duration  of 
this  early  stage,  from  a  few  hours  to  a  day. 

Effusioti  stage  :  The  symptoms  of  this  stage  depend  upon  the  amount 
23 


274  PRACTICE   OF   MEDICINE. 

and  rapidity  of  the  effusion ;  precordial  oppression,  tendency  to 
syncope,  dyspncea,  sometimes  amounting  to  orthopnoea,  dysphagia, 
?iiccough,  nausea  and  vomiting,  feeble,  irregular  pulse,  sometimes 
either  melancholia,  delirium,  or  acute  maniacal  excitement. 

Absorption  is  generally  rapid,  the  heart  remaining  "  irritable"  for  a 
long  time  after.  If,  instead  of  absorption,  the  fluid  accumulates,  and 
life  is  not  destroyed,  the  pericardial  sac  becomes  dilated,  chronic 
pericarditis  resulting. 

Inspection.  Early  stage,  excited  cardiac  action  is  evidenced  by 
the  impulse. 

Effusion  stage,  feeble,  undulatory  or  absent  impulse,  its  position 
displaced  upward,  or  rarely,  downward ;  bulging  of  the  praecordium 
and  protruding  abdomen. 

Palpation.  Early  stage,  excited  or  tumultuous  impulse ;  peri- 
cardial frictio7i  fremitus  rare. 

Effusion  stage,  feeble  or  absent  impulse,  and  if  present  its  position 
is  changed. 

Percussion.     Early  stage,  normal. 

Effusion  stage,  cardiac  dullness  enlarged  vertically  and  laterally, 
and  if  considerable  fluid,  of  a  tria7igular  shape,  with  the  base  of  the 
triangle  on  a  line  with  the  sixth  rib,  extending  from  the  right  of  the 
sternum  to  the  left  of  the  left  nipple,  narrowing  as  it  proceeds  upward 
to  the  second  rib,  or  above,  which  represents  the  apex  of  the  triangle. 
The  shape  of  the  dullness  is  sometimes  altered  by  changing  the  posi- 
tion of  the  patient. 

Auscultation.  Early  stage,  excited  cardiac  action,  and  usually 
a  friction  soujid  (exocardial  murmur)  synchronous  with  cardiac 
sounds  and  uninfluenced  by  respiration,  but  often  increased  by  pres- 
sure with  the  stethoscope. 

Effusion  stage,  cardiac  sounds  feeble  and  deep-seated  at  the  cardiac 
apex,  becoming  louder  and  distinct  toward  the  cardiac  base.  The 
friction  sound  is  sometimes  heard  at  the  cardiac  base. 

If  absorption  occur  the  above  signs  gradually  give  place  to  the 
norma),  the  friction  sound  returning,  ot  a  churning,  or  clicking,  or 
grating  character,  gradually  disappearing. 

Diagnosis.  Endocarditis  is  often  confounded  with  pericarditis, 
the  points  of  distinction  between  which  will  be  pointed  out  when  dis- 
cussing that  affection. 

Cardiac  hypertrophy  or  dilatation  is  sometimes  confounded  with 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  275 

pericardial  effusion  ;  the  difference  between  them  will  be  pointed  out 
when  discussing  those  affections. 

Hydropericardhim  may  be  mistaken  for  pericardial  effusion  ;  see 
that  affection. 

ProgTlGsis.  Controlled  by  the  severity  of  the  inflammation  and 
coexisting  affections.  If  slight  effusion,  favorable.  Death  has  rapidly 
occurred  when  a  large  quantity  of  fluid  has  been  rapidly  effused,  the 
patient  being  really  drowned  in  his  own  fluid.  Adherent  pericardium 
is  a  frequent  sequela. 

Treatment.  Perfect  rest  in  bed  ;  for  vigorous  patients,  the  appli- 
cation of  leeches  or  wet  cups  to  the  prsecordium,  followed  by  the 
application  of  either  ice  or  poultices ;  in  the  feeble  dry  cups  to  the 
praecordium,  followed  by  poultices. 

Early  stage ;  in  the  strong,  control  the  excited  cardiac  action  by 
small  doses  of  aconitum  or  veratrum  viride,  in  the  feeble  using  digi- 
talis ;  in  all  cases  quinina  is  indicated. 

Effusio'ii  stage ;  as  the  effusion  progresses  the  free  administration 
of  alkalies,  to  wit:  ammonii-carb.,  gr.  v,  every  two  hours,  with  liquor 
ainmonii  acetatis,  or  potassii  acetatis,  or  potassii  carbonatis,  with 
quinina,  nutritious  liquid  diet  and  stimulants,  being  cautious  with 
the  use  of  cardiac  sedatives  or  tonics. 

If  the  effusion  has  a  tendency  to  linger,  blisters  to  the  prsecordium, 
or  paracentesis,  is  indicated.  Dr.  Roberts,  in  his  monograph,  gives 
an  account  of  sixty  cases  of  paracentesis  with  twenty-four  recoveries. 
He  advises  that  the  tapping  be  done  in  the  fossa  between  the  ensi- 
form  and  costal  cartilages  on  the  left  side,  or  in  the  fifth  left  interspace 
near  the  junction  of  the  sixth  rib  with  its  cartilage. 

CHRONIC  PERICARDITIS. 

Definition.  A  chronic  inflammation  of  the  pericardium,  with 
either  distention  of  the  sac  by  fluid  or  adhesions  of  the  pericardium 
(adherent  pericardium) ;  characterized  by  impaired  cardiac  action 
and  disturbances  of  the  circulation. 

Causes.     Almost  always  the  result  of  an  acute  attack. 

Pathological  Anatomy.  If  the  effusion  be  absorbed,  the  peri- 
cardial surfaces  are  agglutinated  by  several  layers  of  lymph,  which  in- 
crease the  thickness  of  the  membranes  half  an  inch  or  more,  and  the 
outer  surface  of  the  pericardium  becomes  adherent  to  the  chest  walls. 


276  PRACTICE    OF    MEDICINE. 

If  the  fluid  be  not  absorbed  it  may  progressively  accumulate,  dis- 
tending the  sac  in  all  directions,  displacing  the  diaphragm  and  inter- 
fering with  the  functions  of  the  surrounding  viscera,  or  alow  grade  of 
inflammation  supervenes,  the  fluid  becoming  purulent,  the  disease 
terminating  fatally  after  a  variable  period. 

As  much  as  eight  to  ten  pints  of  fluid  have  accumulated  in  the  sac. 

Symptoms.  Prcecordial  pain  and  distress,  irregular,  fgeble  car- 
diac action,  dysfiH<za  aggravated  by  movement  and  disturbed  cir- 
cidation. 

An  agglutinated  pericardium  seriously  increases  the  danger  from 
an  attack  of  any  pulmonary  inflammation. 

Inspection.  If  the  effusion  be  present,  bulging  of  the  praecor- 
dium  and  displacement  of  the  impulse. 

If  adhesions  are  formed  between  the  praecordial  surfaces  as  well  as 
with  the  chest  walls,  inspection  reveals  depression  of  the  prcBcordiiim, 
narrowing  of  the  spaces,  increased  extent  but  displaced  impulse,  un- 
influenced by  deep  inspiration,  and  recessio?i  of  the  intercostal  spaces 
{systolic  dimpling)  and  epigastrium  with  every  systole  of  the  heart, 
the  result  of  the  adhesions. 

Palpation.  If  effusion,  displaced,  feeble  or  absent  impulse  ;  if 
adhesion,  displaced  and  tumultuous  impulse  ;  occasionally  a  peri- 
cardial fremitus  is  distinguished. 

Percussion.  If  effusion,  the  dullness  has  more  or  less  the  char- 
acter described  for  acute  pericarditis. 

If  adhesions,  the  cardiac  dullness  is  but  slightly  modified. 

Auscultation.  If  effusion,  cardiac  sounds  feeble  and  deep-seated 
at  the  apex,  louder  and  more  distinct  at  the  cardiac  base. 

If  adhesions,  cardiac  sounds  are  heard  with  equal  distinctness  in 
their  several  positions,  associated  with  a  rough  friction  sound  (exo- 
cardial  murmur). 

Treatment.  If  effusion,  blisters  to  the  pmecordium,  with  potassii 
iodidiini  to  hasten  absorption,  the  patient  supported  by  nutritious  diet, 
quinina,  ferrwn  and  stimulants,  and  perfect  c^uiet.  If  these  means 
fail  to  remove  the  fluid,  or  if  the  fluid  be  y^\xx\A(tx\\.,  paracentesis  should 
be  performed  at  once. 

If  adhesions  of  the  pericardiuin  have  resulted,  the  application  of 
blisters  to  the  praecordium  with  the  administration  of  potassii  iodi- 
dum,  alternating  with  ferritin  and  quinina,  are  indicated,  with  nutri- 
tious diet,  stimulants  and  perfect  quiet. 


DISEASES   OF   THE   CIRCULATORY  SYSTEM.  277 

HYDRO-PERICARDIUM. 

Synonym.     Pericardial  dropsy. 

Definition.  The  accumulation  of  water  in  the  pericardial  sac, 
minus  inflammation  ;  characterized  by  praecordial  distress,  disturbed 
cardiac  action,  dyspnoea  and  dysphagia. 

Causes.  Ubually  a  part  of  a  general  dropsy  ;  Bright's  disease ; 
sudden  pneumothorax  ;  pressure  of  an  aneurism  or  other  mediastinal 
tumor ;  disease  or  thrombosis  of  the  cardiac  veins. 

Pathological  Anatomy.  The  fluid  may  range  in  quantity  from 
an  ounce  to  one  or  two  pints,  and  is  of  a  clear,  yellowish  or  straw- 
colored  serum,  at  times  turbid  or  bloody,  and  of  an  alkaline  reaction. 

If  the  amount  of  fluid  be  large  the  sac  is  dilated,  its  walls  thinned 
by  the  pressure,  and  has  a  sodden  appearance. 

Symptoms.  Dropsy  of  the  pericardium  is  so  generally  associated 
with  hydrothorax  that  the  symptoms  are  but  an  aggravation  of  those 
attending  upon  that  condition,  to  wit:  disturbed  cardiac  action,  dysp- 
ncea,  dysphagia,  dry  cough,  and  feeble  circulation. 

The  physical  signs  are  exactly  those  of  the  stage  of  effusion  of 
pericarditis,  minus  a  friction  sound. 

Diag'nosis.  Pericarditis  with  effusion  and  hydro-pericardium 
present  nearly  the  same  signs  and  symptoms,  a  differentiation  being 
possible  only  by  a  history  of  the  case  and  the  symptoms  of  the  attack. 

Prognosis.     Controlled  entirely  by  the  cause. 

Treatment.  Depends  upon  the  cause  of  the  attack.  If  the 
amount  of  fluid  in  the  pericardial  sac  be  great,  paracetitesis  will  give 
relief. 

ACUTE  ENDOCARDITIS. 

Sjmonym,     Valvulitis. 

Definition.  An  acute  fibrinous  inflammation  of  the  serous  mem- 
brane lining  the  cavity  of  the  heart  and  forming  its  valves ;  charac- 
terized by  cough,  dyspnoea,  nausea  and  vomiting,  disturbed  cardiac 
action,  resulting  in  changes  in  the  valves  or  orifices  of  the  heart. 

Acute  endocarditis  occurs  in  two  distinct  forms :  plastic  or  simple 
exudative  endocarditis  ;  ulcerous  or  diphtheritic  endocarditis. 

Causes.  Usually  secondary  to  acute  articular  rheumatism,  pleu- 
ritis,  pneum.onia,  pericarditis  or  Bright's  disease.  In  the  ulcerative  or 
diphtheritic  variety,  a  depressed  condition  of  the  vital  forces,  probably 
the  result  of  the  diphtheritic  poison,  seems  to  be  the  determining  cause. 


278  PRACTICE   OF   MEDICINE. 

Pathological  Anatomy.  Inflammation  of  the  endocardium  is 
usually  limited  to  the  left  side  of  the  heart  after  birth,  durins^  foetal 
life  the  reverse  being  the  case.  The  inflammation  is  limited  or  espe- 
cially marked  at  the  valvular  portions  of  the  endocardium,  owing 
probably  to  the  presence  of  fibrous  tissue  beneath  the  menibrane  in 
these  situations,  and  to  the  strain  which  falls  upon  the  valves  during 
the  performance  of  their  functions. 

Hyperemia  from  congestion  of  the  vessels  beneath  the  membrane, 
with  considerable  swelling  of  the  valves,  the  result  of  an  exiidatioK 
of  lymph  and  scrum  beneath  and  on  the  free  surface  of  the  membrane 
covering  the  valves  and  chorda  fendinecB,  resulting  in  the  roughening 
of  the  surfaces  and  the  agglutination  of  the  mitral  valves  to  each 
other,  and  of  the  aorta  segments  to  the  walls  of  the  aorta,  or  the  pro- 
liferation of  the  endocardial  connective  tissue,  forming  the  nuclei  of 
the  so-called  warty  excrescences  or  vegetations,  their  size  being  in- 
creased by  the  deposit  of  fibrin  from  the  blood  within  the  cavities 
of  the  heart. 

These  vegetations  maybe  detached  by  friction,  giving  rise  to  emboli 
which  may  be  washed  by  the  blood  current  on  the  left  side  of  the 
brain,  into  the  kidneys  and  spleen. 

In  the  ulcerative  variety  a  process  of  softening  takes  place  in  the 
fibrinous  deposits,  leading  to  ulcerations  and  perforations. 

Syraptoms.  This  afl"ection  is  usually  masked  by  the  course  of 
another  disease  until  disturbances  of  the  circulation  attract  attention 
to  the  heart. 

The  onset  is  often  by  i7icrease  of  temperature,  prcecordial  distress, 
short  cough,  slight  dyspnoea,  more  or  less  persistent  vomiting,  in- 
creased cardiac  action,  often  rapid  and  tumultuous,  with  throbbing 
carotids  and  noises  in  the  ear.  As  the  inflammation  progresses,  the 
cardiac  action  and  pulse  decline  in  rapidity,  with  more  or  less  con- 
gestion of  the  lungs  and  venous  stasis. 

Auscultation.  Shows  a  change  in  the  character  of  the  sounds 
or  the  development  of  murmurs  at  the  various  orifices,  the  character 
and  points  of  distinction  between  which  will  be  pointed  out  when 
discussing  valvular  diseases  of  the  heart. 

Duration.     Between  one  and  three  weeks. 

Diagnosis.  Pericarditis  h  distinguished  from  endocarditis  by  the 
character  of  the  physical  signs.  In  pericarditis  the  murmur  or  friction 
sound  is  heard  with  either  sound,  is  near  to  the  ear  and  influenced  by 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  279 

pressure  of  the  stethoscope,  besides  being  associated  with  more  or  less 
alteration  in  the  size  and  shape  of  the  cardiac  dullness,  and  is  not 
transmitted,  while  in  endocarditis  the  murmur  takes  the  place  of,  or 
is  associated  with,  the  cardiac  sounds,  and  is  transmitted,  with  the 
absence  of  change  or  increased  dullness  on  percussion. 

Prognosis.  Acute  endocarditis  is  not  very  dangerous  to  life, 
hence  a  favorable  prognosis  may  be  given  ;  regarding  the  ultimate 
results  of  valvular  lesions,  however,  the  prognosis  is  grave. 

Treatment.  Perfect  rest  in  bed.  At  the  onset  leeches  or  wet  cups 
to  the  prsecordium,  followed  by  ice,  or,  what  is  preferable,  j?^^^^///^^^. 

The  excited  circulation  should  be  controlled  by  aconitum,  veratrum 
viride,  or  digitalis. 

The  free  administration  of  alkalies,  to  wit :  aminonii  carbonas, 
potassii  acetas  or  carbonas,  until  the  urine  is  decidedly  alkaline,  may 
prevent  permanent  changes  in  the  valves  or  orifices. 

If  alkalies  fail  and  the  inflammation  shows  a  tendency  to  linger, 
good  results  are  often  obtained  by  a  slight  hydrargyrum  impression. 

If  signs  of  oppressed  circulation  appear,  the  hands  becoming  blue, 
the  face  and  extremities  oedematous,  with  congestion  of  the  lungs, 
the  free  use  of  a7ninonii  carbonas,  digitalis  and  stimulants  is  indi- 
cated. The  free  use  of  ammonii  carbonas  will  often  prevent  or  break 
up  heart  clots.  After  the  acute  symptoms  have  subsided,  more  or 
less  absorption  of  the  exuded  lymph  has  followed  the  free  use  of 
potassii  iodidum.  During  the  entire  course  of  the  affection  the  diet 
should  be  of  the  most  nutritious  character. 


ACUTE  MYOCARDITIS. 

Definition.  An  inflammation  of  the  muscular  tissue  of  the  heart, 
by  extension  from  an  inflamed  pericardium  or  endocardium,  or  sec- 
ondary to  pyaemia  ;  characterized  by  pain,  feeble  circulation,  symp- 
toms of  blood  poisoning  and  collapse. 

Causes.  The  result  of  endocarditis  or  pericarditis  ;  pysemia ; 
typhoid  fever  ;  emboli  of  the  coronary  arteries. 

Pathological  Anatomy.  Discoloration  and  softening  of  the 
cardiac  substance  and  the  infiltration  of  a  sero-sanguineous  fluid, 
fibrinous  exudation  and  pus,  leading  to  the  formation  of  abscesses 
in  the  muscular  structure  of  the  heart. 

The  disease  leads  to  the  formation  of  either  a  cardiac  aneurism  or 


280  PRACTICE   OF   MEDICINE. 

to  rupture  of  the  walls  of  the  heart.  If  recovery  occur,  cicatrices  or 
depressed  scars  may  mark  the  site  of  a  former  abscess. 

Symptoms.  The  clinical  evidences  of  inflammation  of  the  car- 
diac muscle  are  very  obscure.  If,  during  the  course  of  one  of  the 
maladies  mentioned,  there  are  developed  pain,  irregular  and  feeble 
cardiac  action,  pyrexia  of  a  low  type,  with  symptoms  of  blood  poison- 
ing, and  a  tendency  to  collapse,  or  the  symptoms  of  the  so-called 
typhoid  state,  myocarditis  may  be  suspected. 

Diagnosis.  The  existence  of  myocarditis  can  scarcely  ever  be 
anything  but  a  presumption,  the  signs  being  all  negative  rather  than 
positive.  If  during  the  course  of  rheumatism,  pyaemia,  puerperal 
fever,  typhoid  fever,  pericarditis  or  endocarditis,  symptoms  of  cardiac 
failure  appear  suddenly,  associated  with  signs  of  blood  poisoning  and 
collapse,  inflammation  of  the  cardiac  muscle  may  be  suspected. 

Prognosis.  The  course  of  acute  myocarditis  is  very  rapid,  death 
being  the  usual  termination,  in  from  three  to  five  days.  Chronic 
myocarditis  pursues  a  very  latent  course. 

Treatment.  Largely  symptomatic.  Perfect  rest  of  mind,  gen- 
erous diet,  free  stimulation  and  the  administration  of  quinina  and 
femnn. 

CARDIAC  HYPERTROPHY. 

Definition.  An  overgrowth  or  increase  in  the  muscular  tissue 
which  forms  the  walls  of  the  heart ;  characterized  by  forcible  impulse  ; 
over-fullness  of  the  arteries,  diminished  blood  in  the  veins  and 
accelerated  circulation. 

Causes.  Obstruction  of  the  outflow  of  blood,  to  wit :  aortic  sten- 
osis ;  emphysema  ;  Bright's  disease  ;  functional  over-action  ;  excessive 
use  of  tobacco,  tea,  coffee,  or  excessive  muscular  action. 

Varieties.  I.  Simple  hypertrophy ,  or  a  simple  increase  in  the 
thickness  of  the  cardiac  walls;  II.  Eccentric  hypertrophy,  increase 
in  the  cardiac  walls  and  dilatation  of  the  cavities,  to  wit  :  Dilated 
hypertrophy :  III.  Concentric  hypertrophy,  increase  in  the  cardiac 
walls  and  decrease  of  the  cavities,  a  very  rare  form. 

Pathological  Anatomy.  Hypertrophy  of  the  heart  is  usually 
limited  to  the  left  side,  the  ventricliss  more  commonly  than  the 
auricles,  the  latter  dilating. 

The  shape  of  the  heart  is  altered  by  hypertrophy  ;  if  the  right 
ventricle,  .the  heart  is  widened  transversely  and  the  apex  blunted  ;  if 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  281 

the  left  ventricle,  the  heart  is  elongated  and,  as  a  rule,  the  cavity  is 
dilated  ;  if  both  ventricles  arehypertrophied,  the  heart  has  a  globular 
shape.  From  increase  in  weight  the  heart  may  sink  lower  during  the 
recumbent  position,  thereby  lessening  the  area  of  cardiac  dullness, 
but  during  the  sitting  or  upright  posture  it  sinks  lower  in  the  chest 
and  to  the  left,  causing  more  or  less  prominence  of  the  abdomen. 

The  increase  in  the  size  of  the  organ  is  a  true  increase  or  hyper- 
trophy of  the  muscular  tissue,  and  not  a  hyperplasia.  The  tissue  is 
firmer  and  the  color  brighter  and  fresher  than  when  the  size  of  the 
organ  is  normal. 

Symptoms.  Depend  upon  the  amount  of  hypertrophy.  The 
most  common  are  increased  arid  forcible  cardiac  atr//^;?,  the  arteries 
becoming  fuller,  the  veins  less  full  and  the  circulation  accelerated, 
pulsating  carotids  and  aorta,  headache,  often  vertigo,  frequent  epis- 
taxis,  congestion  of  the  face  and  eyes,  tinnitus  auriuin,  dysp7icea  on 
exertion, /fry  r^z/T^^,  restless  nights,  with  more  or  less  jerking  of  the 
limbs,  occasional  praecordial  pains  shooting  toward  the  left  axilla, 
full,  firm,  bounding  pulse,  and  pulsations  in  the  superficial  arteries. 

A  sphygmographic  tracing  shows  the  line  of  ascent  vertical  and 
abrupt,  but  the  apex  is  rounded,  and  the  line  of  descent  is  oblique, 
unless  there  is  more  or  less  insufficiency  of  the  valves. 

Inspection.  Often  fullness  or  prominence  of  the  praecordium, 
with  distinct  impulse. 

Palpation.  The  impulse  is  felt  one  or  two  intercostal  spaces 
lower  down  and  to  the  left,  and  is  stronger  and  more  or  less  diffused 
— the  heaving  impulse. 

Percussion.  The  area  of  cardiac  dullness  is  increased  vertically 
and  transversely  upon  the  left  side  of  the  sternum,  unless  the  right 
ventricle  is  also  hypertrophied,  when  the  cardiac  dullness  is  increased 
to  the  right  of  the  sternum. 

Auscultation.  If  simple  hypertrophy  without  any  coexisting 
changes  in  the  valves  or  orifices,  the  first  sound  has  a  loud  and  some- 
what metallic  quality,  the  second  sound  being  strongly  accentuated. 

Sequelae.  Cerebral  hemorrhage ;  miliary  cerebral  aneurisms ; 
dilatation  of  the  heart ;  fatty  changes  in  the  cardiac  tissue. 

Diag'nosis.  Hypertrophy  of  the  heart  can  scarcely  be  mistaken 
for  any  other  disease  if  a  careful  study  of  the  physical  signs  be  made. 

Prognosis.  When  the  result  of  valvular  disease,  the  hypertrophy 
is  said  to  be  compensatory.     If  the  result  of  Bright's  disease,  emphy- 


282  PRACTICE   OF   MEDICINE. 

sema  of  the  lung,  or  if  occurring  late  in  life,  or  associated  with  athero- 
matous degeneration  of  the  vessels,  the  prognosis  is  unfavorable ; 
when  the  result  of  functional  over-action  in  the  strong  and  robust,  a 
further  enlargement  can  often  be  prevented  by  active  and  persistent 
treatment. 

Treatment.  The  indications  are  to  lesse7i  the  force  and  number 
of  the  cardiac  pulsations  and  to  remove  the  cause  whenever  possible. 

The  former  indications  are  best  met  by  the  persistent  use  of  aconi- 
ium  in  small  doses,  gtt.  j-ij,  three  times  a  day,  or  veratriim  vin'de, 
gtt.  j-ij,  three  times  a  day,  at  the  same  time  keeping  the  bowels, 
kidneys  and  skin  acting  freely. 

The  habits  of  the  patient  are  to  be  corrected,  all  laborious  or  active 
exercise  to  be  restricted,  the  patient  to  be  in  the  recurribent  posture 
several  hours  during  the  day  if  possible,  the  diet  being  restricted, 
avoiding  all  forms  of  stimulants,  such  as  liquors,  tobacco,  tea  and 
coffee. 

Cases  of  cardiac  hypertrophy  associated  with  Bright's  disease  are 
relieved  by  digitalis,  the  cardiac  distress  being  secondary  to  the  kid- 
ney disease  for  which  the  digitalis  is  used. 

Cases  of  cardiac  hypertrophy  associated  with  anaemia  should,  in 
addition  to  the  above,  be  placed  upon  a  course  oiferrum. 


DILATATION   OF   THE    HEART. 

Definition.  An  increase  in  the  size  of  one  or  more  of  the  cavities 
of  the  heart,  without  any  increase  or  thickening  of  the  cardiac  walls  ; 
in  fact,  the  walls  are  frequently  thinner  ;  characterized  by  feebleness  of 
the  circulation,  terminating  in  venous  stasis,  oedema  and  exhaustion. 

Causes.  Over-exertion  in  those  of  feeble  resisting  powers,  as 
youths  or  soldiers,  as  first  pointed  out  by  Prof.  Da  Costa ;  insuffi- 
ciency of  the  valves  ;  emphysema  ;  chronic  bronchitis  ;  gout ;  Bright's 
disease. 

Varieties.  I.  Simple  dilatation,  the  cavities  being  enlarged,  the 
walls  normal.  II.  Active  dilatation,  corresponding  to  eccentric 
hypertrophy ;  the  cavities  being  enlarged  and  the  walls  increased  in 
thickness,  the  so-called  "  dilated  hypertrophy."  III.  Passive  dilata- 
tion, the  cavities  being  enlarged  and  the  walls  thinned  or  stretched. 

Pathological  Anatomy.  The  right  side  of  the  heart  is  far 
more  frequently  involved  than  the  left  side.     The  shape  of  the  organ 


DISEASES   OF  THE   CIRCULATORY   SYSTEM.  283 

is  altered,  according  to  the  part  affected.  The  weight  of  the  organ  is, 
as  a  rule,  increased,  as  hypertrophy  almost  always  accompanies  or 
precedes  dilatation. 

The  muscular  tissue  is  generally  pale,  mottled  and  softened,  and 
under  the  microscope  presents  evidences  of  degeneration.  The  orifices 
also  participate,  and  especially  the  auriculo-v^entricular,  resulting  in 
the  valves  becoming  incompetent  to  close  the  orifices,  and  this  latter 
effect  is  added  to  by  the  removal  of  the  basis  of  the  papillary  muscles 
to  a  great  distance  from  the  orifice,  in  consequence  of  the  extension 
of  the  wall. 

When  the  auricles  dilate,  the  large  venous  trunks  opening  into  them 
unprotected  by  valves  commonly  participate  in  the  dilatation,  and 
may  become  greatly  enlarged. 

The  passive  congestion  of  the  organs  that  follows  the  feeble  circu- 
lation produces  changes  in  their  structure. 

Symptoms.  Those  associated  with  enfeebled  circulation,  to  wit : 
feeble  pulse,  veins  distended,  arteries  emptied,  headache,  aggravated 
by  the  upright  position,  attacks  oi  syncope,  cough,  with  any  of  the  fol  ■ 
lowing  phenomena  of  venous  congestion  ;  of  the  lungs,  dyspncea  ; 
\\v ox,  jaundice ;  stomach,  dyspepsia;  intestines,  cons/ipation  ;  kid- 
neys, scanty,  often  albuminous,  tirine  ;  brain,  dullness  of  the  mind  and 
vertigo,  often  relieved  by  a  copious  epistaxis  ;  and,  finally,  dropsy, 
beginning  in  the  lower  extremities,  the  patient  dying  from  exhaustion. 

Great  relief  often  temporarily  follows  any  of  the  above  symptoms 
under  treatment ;  sooner  or  later,  however,  the  venous  stasis  produces 
the  final  symptoms  noted. 

Inspection.  Veins  of  the  surface  distended  and  enlarged  ;  in- 
distinct cardiac  impulse,  often  diffused  and  wavy  ;  if  associated  with 
tricuspid  insuf^ciency,  there  is  pulsation  of  the  jugular. 

Palpation.     Feeble  and  irregular  fluttering  but  heaving  impulse. 

Percussion.  Cardiac  dullness  extended  transversely,  and  espe- 
cially increased  on  the  right  side. 

Auscultation.  If  no  valvular  lesion  accompany  the  dilatation 
the  cardiac  sounds  are  weaker  than  normal,  the  first  sounds  having  a 
sharper  quality  than  normal;  if  accompanied  by  valvular  lesions, 
cardiac  murmurs  are  present. 

Diagnosis.  Hypertrophy  of  the  heart  shows  increased  cardiac 
dullness,  and  is  a  disease  of  powerful  cardiac  action,  while  dilatation 
is  an  affection  of  feeble  action  associated  with  dropsy. 


284  PRACTICE   OF   MEDICINE. 

Pericardial  effusion  has  many  points  of  resemblance  to  cardiac 
dilatation,  but  it  begins  suddenly,  associated  with  some  acute  malady; 
and  while  the  heart  sounds  are  indistinct  or  feeble  at  the  apex,  they 
both  have  their  normal  qualities  at  the  cardiac  base,  while  dilatation 
of  the  heart  has  a  chronic  history,  results  in  general  venous  stasis,  the 
cardiac  sounds  being  of  the  same  intensity  over  the  entire  proscordia. 

Prognosis.  Unfcivorable,  death  resulting  from  gradual  exhaus- 
tion, or  suddenly  by  cardiac  paralysis  if  there  be  undue  excitement. 

Treatment.  Dilatation  of  the  heart  is  incurable.  Palliative 
measures  are  of  but  temporary  benefit.  In  all  cases  there  are  two 
important  indications  to  be  met,  the  first  to  maintain  the  general 
nutrition  of  the  patient  to  the  uttermost,  and  the  second  to  control  or 
prevent  all  irregular  or  violent  cardiac  action.  The  first  indication  is 
accomplished  by  a  generous  diet,  moderate  exercise,  with  bitters  to 
increase  the  appetite  and  ferrwn  to  improve  the  blood,  and,  in  a 
majority  of  cases,  the  more  or  less  free  use  of  a  good  red  wine. 

The  second  indication  is  met  by  the  observance  of  strict  rules  in 
regard  to  exercise  and  such  heart  tonics  as  digitalis  in  powder  or 
infusion,  tinctura  strophanthiis  Y(\j.]-x,  t.  d.,  exi.  cotivallarice  fld.,  gtt. 
V,  t.  d.,  guinina,  caffeina  and  morphincz  siclph.,  in  small  doses,  the 
latter,  when  the  dropsy  becomes  great  and  associated  with  marked 
cyanosis,  hypodermically,  as  suggested  by  Prof.  Bartholow,  "  often 
acts  like  magic  in  restoring  the  circulation." 

The  following  pill  is  often  of  great  advantage, — 

R .     Ferri  redact., gr.  j-ij 

Quininse  sulph., gr.  j-ij 

Pulv.  digitalis, gr.  j 

Morphina;  sulph., gr.  ^'j.  M. 

SiG. — Three  times  a  day. 

The  secretions  should  be  stimulated  by  purgatives ,  diuretics  and 
diaphoretics. 

If  pulmonary  congestion,  dry  cups,  digitalis  and  stimulants. 

For  cardiac  asthma,  dry  cups,  viorphiufp.  sulph.  hypodermically,  or 
spts.  (ztheris  compositus  (Hoffman's  Anodyne). 

For  hepatic  congestion,  bhte  mass  ox  podophyllin. 

For  dropsy,  dry  cups  over  the  kidney,  digitalis  or  potassii  acetas, 
with  scoparius  2Si(S.juniperiis,  ^x\A  pulv.  jalapa;  coinp.,  3j-'ji  in  water, 
before  breakfast. 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  285 

If  the  dropsy  is  uninfluenced  by  the  above  means,  success  will  follow 
the  use  of  hydrargyri  chloridi  mite,  gr.  iij,  guarded  with  piUv.  opii, 
gr.  j^2>  three  or  four  times  a  daj',  as  I  have  frequently  witnessed. 


FATTY  DEGENERATION  OF  THE  HEART. 

Definition.  A  change  in  the  muscular  fibres  of  the  heart,  in 
which  the  transverse  strice  are  replaced  by  granules  and  globules 
of  fat;  characterized  by  feeble  cardiac  action,  venous  stasis  and 
dyspnoea. 

Causes.  Impaired  nutrition  in  the  elderly ;  prolonged  anaemia  ; 
chronic  gout ;  alcoholism  ;  phosphorus  poisoning ;  cancer  ;  tubercu- 
losis and  scrofula  ;  disease  of  the  coronary  arteries. 

Pathological  Anatomy.  The  distinction  must  be  made  be- 
tween a  deposit  of  fatty  tissue  upon  or  around  the  heart,  and  the 
degeneration  of  its  muscular  tissue. 

The  fatty  metamorphosis  may  affect  the  whole  organ,  or  the  entire 
ventricles,  or  be  limited  to  portions  of  them.  If  the  degeneration  be 
marked  the  color  is  yellowish,  the  tissues  soft  and  easily  torn,  and  to 
the  touch  have  a  greasy  feeling,  oil  being  yielded  on  pressure. 

The  microscopic  changes  are  characteristic.  The  striae  of  the 
muscle  are  easily  rendered  indistinct  by  fat  and  oil  globules,  gradually 
becoming  more  and  more  obscured,  and  finally  disappearing  alto- 
gether, the  fibres  being  replaced  by  fat  granules. 

Symptoms.  Those  of  weak  heart,  anaemia  of  organs  and  venous 
stasis,  to  wit :  feeble,  irregular,  but  slow  cardiac  actiofi,  couipressible 
pulse,  prcscordial  distress,  often  aggravated  by  attacks  of  angina  pec- 
toris ;  dyspncea,  aggravated  on  exertion,  with  anaemia  of  the  various 
organs  from  the  feeble  propulsive  power ;  if  of  brain,  vertigo,  swoon- 
ing, or  pseudo-epileptic  attacks,  especially  marked  on  suddenly  rising 
from  a  recumbent  position  ;  if  of  lungs,  dry,  hacking  cough  ;  if  of 
gastro-intestinal  tract,  dyspepsia  and  constipatioii ;  if  of  kidneys, 
scanty  urine,  at  times  albuminous  ;  and  finally,  dropsy,  beginning  in 
the  lower  extremities. 

A  formidable  symptom,  causing  much  inconvenience  as  well  as 
alarm  to  the  patient,  is  what  he  will  term  his  constant  "  sighing,"  the 
Cheyne-Stokes  breathing — "A  pause  in  the  breathing,  a  complete 
suspension  of  the  respiratory  acts  for  a  period  of  time  (during  which 
breathing  might  occur  several  times  in  the  normal  manner),  then  the 


286  PRACTICE   OF   MEDICINE. 

resumption  of  respiration  very  feebly  and  slowly,  and  a  gradual  and 
progressive  increase  in  the  number  and  depth  of  respirations  until  the 
maximum  is  reached,  and  then  again  a  gradual  and  progressive 
diminution,  in  the  same  order,  in  the  number  and  depth  of  the  res- 
pirations, until  another  pause  occurs  " — the  "  oscillating  respiration." 

Concomitant  symptoms  are  atheromatous  change  in  the  vessels, 
and  the  arc  us  sefii/is. 

Palpation.     Weak  cardiac  impulse. 

Percussion.  Not  markedly  changed  unless  preceded  by  enlarge- 
ment of  the  heart. 

Auscultation.  First  sound  feeble,  toneless,  almost  inaudible, 
the  second  sound  being  normal,  unless  changes  in  the  valves  are 
present. 

Diagnosis.  If  aged  persons,  or  those  exposed  to  the  causes,  have 
feeble  heart,  associated  with  atheroma  of  the  vessels  and  the  arcus 
senilis,  the  diagnosis  of  fatty  heart  is  almost  positive.  If  dropsy  occur, 
however,  it  is  difficult  to  distinguish  from  dilatation  of  the  heart. 

Prognosis.  Incurable,  the  affection  pursuing  a  more  or  less 
chronic  course.  Life  may  be  prolonged  at  times  by  treatment,  but 
death  finally  results  from  exhaustion,  or  suddenly,  from  cardiac 
paralysis  or  rupture  of  the  heart. 

Treatment.  Incurable,  there  being  no  plan  of  treatment  that  can 
restore  the  degenerated  muscular  fibre.  Generous  diet,  very  moderate 
exercise,  stimulants,  oleum  morrhucE,  and  the  "triple  elixirs," — elixir 
ferri,  quitiijicE  et  strycJinincE. 

All  the  excreting  organs  must  be  kept  active,  so  as  to  relieve  the 
crippled  heart  as  much  as  possible. 

To  sustain  the  cardiac  action,  caffeina  or  inorphina  in  small  doses, 
or  hypodermically  for  the  so  called  cardiac  asthma.  Digitalis  is 
contra-indicated  in  advanced  cases. 

Quain  says:  "  Galva7iism  applied  from  the  back  of  the  neck  to  the 
praicordium,  by  the  interrupted  current,  has  been  found  useful." 

VALVUL.\R  DISEASES  OF  THE  HEART. 

Definition.  Alterations  in  the  cardiac  valves  or  orifices,  render- 
ing the  former  incapable  of  properly  closing  the  latter,  or  causing  the 
latter  to  interrupt  the  blood  current  in  its  normal  movement. 

The  lesions  are  of  two  kinds,  to  wit :  obstructive  and  regurgitant. 


DISEASES   OF   THE   CIRCULATORY   Si'STEM.  287 

A  regurgitajit  lesion,  termed  also  insufficiency ,  is  such  change  in  the 
valves  as  to  permit  a  portion  of  the  blood  to  flow  backward  instead 
of  onward,  the  true  direction  of  the  blood  current. 

An  obstructive  lesion,  termed  also  stejtosis,  is  a  narrowing  of  the 
orifice,  thereby  obstructing  the  passage  of  the  blood. 

Varieties.  I.  Mitral  regurgitation,  II.  Aortic  regurgitation.  III. 
Tricuspid  regurgitation.  IV.  Pulmonic  regurgitation.  V.  Mitral 
obstruction.  VI.  Aortic  obstruction.  VII.  Tricuspid  obstruction. 
VIII.  Pulmonic  obstruction. 

Causes.  In  the  young,  usually  the  result  of  endocarditis,  and 
generally  affecting  the  mitral  orifice  or  valves  ;  in  the  elderly,  chronic 
endocarditis  or  atheromatous  degeneration,  most  commonly  affecting 
the  aortic  orifice  or  valves. 

Prof.  Da  Costa  has  clearly  established  the  production  of  aortic  dis- 
ease in  early  life  by  overwork  and  strain  of  the  heart ;  syphilis  ; 
dilatation  of  the  heart ;  atrophy  or  contraction  of  the  valves,  and 
congenital  malformations. 

MITRAL   REGURGITATION. 

Patholog'ical  Anatomy.  The  most  common  conditions  ob- 
served are  more  or  less  contraction  and  narrowing  of  the  tongues  of 
the  valves,  with  irregular  thickening  and  rigidity  ;  atheroma  or  calci- 
fication of  the  segments  ;  laceration  of  one  or  more  segments  ;  adhe- 
sion of  one  or  more  segments  to  the  inner  surface  of  the  ventricle  ; 
rupture  of  the  chordcB  tendincB,  and  also  contraction  and  hardening 
of  the  musculi  papillares. 

As  a  result  of  the  regurgitation  of  the  blood  into  the  left  auricle, 
there  is  dilated  hypertrophy. 

Symptoins.  Insufficiency  of  the  mitral  valves  soon  leads  to  car- 
diac hypertrophy,  to  compensate  for  the  diminished  amount  of  blood 
sent  onward  by  the  ventricular  systole.  When  the  "compensation 
ruptures  "  there  occurs  prcecordial  distress,  cough,  dyspnoea,  feeble, 
soft,  rapid,  irregular  pulse  ;  finally  pulmonary  congestion,  cedematous 
limbs,  the  abdominal  cavity  filled,  liver  congested,  urine  scanty  and 
albuminous,  the  patient  dying  "  drowned  in  his  own  fluid." 

Inspection.  Cardiac  impulse  lower  than  normal,  the  heart  being 
enlarged. 

Palpation.  Early,  forcible  and  diffused  impulse ;  later,  feeble 
diffused  impulse. 


288  PRACTICE   OF   MEDICINE. 

Percussion.    Transverse  and  vertical  cardiac  dullness  increased. 

Auscultation.  Systolic  blowing  or  churning  murmur,  audible 
in  the  mitral  area,  propagated  to  the  apex,  left  axilla  and  under  the 
angle  of  the  scapula,  either  occurring  with  or  taking  the  place  of  the 
first  sound  of  the  heart ;  the  second  sound  markedly  accentuated. 

Prognosis.  So  long  as  the  compensating  hypertrophy  can  be 
maintained  the  prognosis  is  not  unfavorable  ;  when  dilatation  super- 
venes, however,  the  patient  soon  perishes,  either  from  congestion  of 
the  lungs  or  dropsy  and  exhaustion. 

AORTIC    REGURGITATION. 

Pathological  Anatomy.  The  valves  or  segments  adhere  to  the 
walls  of  the  aorta,  or  a  segment  is  lacerated  or  may  be  perforated,  or, 
more  commonly,  the  segments  are  shrunken,  deformed  and  rigid,  per- 
mitting the  regurgitation  of  the  blood.  These  deficiencies  in  the  valves 
are  usually  associated  with  more  or  less  narrowing  of  the  orifices. 

The  cardiac  muscle  rapidly  hypertrophies,  its  cavity  enlarging — 
dilated  hypertrophy. 

Symptoms.  Those  of  marked  hypertrophy,  to  wit :  forcible  car- 
diac action,  headache,  tinnitus  aurium,  congestion  of  the  face  and 
eyes,  with  pulsating  vessels,  even  small  ones  pulsating  that  before 
were  not  visible  to  the  eye  ;  pulsations  of  the  retinal  vessels  can  be 
recognized  with  the  ophthalmoscope  ;  the  recedmg  pulse,  which  is 
particularly  characteristic — forcible  impulse  but  rapidly  declining, 
called  "  water-hammer  "  pulse  ;  also,  the  "  Corrigan  pulse." 

When  "  compensation  ruptures,"  dyspnoea,  cough,  hepatic  enlarge- 
ment, congestion  of  the  kidneys,  with  scanty,  albuminous  urine,  ascites 
and  dropsy.  If  mitral  insufficiency  is  now  superadded,  general 
venous  stasis  and  death  rapidly  occur. 

Inspection.     Forcible  cardiac  muscle. 

Palpation.     Strong,  full  cardiac  impulse. 

Percussion.  Cardiac  dullness  increased  transversely  and  verti- 
cally. 

Auscultation.  First  sound,  forcible;  second  sound,  replaced  or 
associated  with  a  chur?iing,  rushing  or  blowing  murmur  of  low  pitch, 
distinct  at  the  second  right  costal  cartilage,  but  most  distinct  at  the 
junction  of  the  sternum  and  the  fourth  left  costal  cartilage,  trans- 
mitted downward  toward  and  below  the  apex. 

Prognosis.     The  one  valvular  disease   most  likely  to  occasion 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  289 

sudden  death  ;  still,  so  long  as  the  compensating  hypertrophy  remains 
intact,  compatible  with  quite  an  active  life. 


TRICUSPID    REGURGITATION. 

Pathological  Anatomy.  This  form  of  valvular  insufficiency 
is  either  associated  with  right-sided  cardiac  dilatation  from  pulmonary 
obstruction,  or  is  the  result  of  mitral  disease. 

The  tricuspid  orifice  is  dilated  in  the  majority  of  cases ;  occasion- 
ally the  segments  of  the  valves  are  contracted  or  adherent  to  the 
ventricle. 

Symptoms.  Venous  stasis  with  its  various  consequences,  and 
especially  pulsation  of  the  jicgular,  synchronous  with  the  cardiac 
movement,  and  finally  general  venous  pulsation,  especially  of  the 
liver,  pulmonary  congestion,  engorgement  of  the  kidneys  and  dropsy. 
These  symptoms  are  superadded  to  those  of  the  affections  with  which 
tricuspid  insufficiency  is  always  associated. 

Inspection.  Diffused,  wavy,  cardiac  impulse;  jugular  pulsation 
synchronous  with  the  cardiac  movement,  uninfluenced  by  respiration, 
also  more  or  less  prominent  hepatic  pulsation. 

Palpation.     The  cardiac  impulse  extended,  but  feeble. 

Percussion.  Dullness  on  percussion,  extending  to  the  right  and 
below  the  sternum. 

Auscultation.  The  first  sound  is  accompanied  by  a  blowing 
murmur  most  intense  at  the  junction  of  the  fourth  and  fifth  ribs  with 
the  sternum,  distinct  over  the  xiphoid  appendix,  becoming  feeble  or 
lost  in  the  left  axillary  region  ;  often  associated,  however,  with  a  mitral 
systolic  murmur. 

PULMONIC    REGURGITATION. 

Pathological  Anatomy.  Insufficiency  of  the  pulmonary  valves 
is  of  rare  occurrence,  but  when  present  the  changes  correspond  more 
or  less  with  those  described  for  aortic  regurgitation. 

Symptoms.  Those  of  dilatation  of  the  right  side  of  the  heart 
and  consequent  pulmonary  congestion,  to  wit:  dyspnoea,  deficient 
aeration  of  the  blood,  and  cyanosis,  distention  of  the  superficial  ves- 
sels, palpitation  of  the  heart,  praecordial  distress,  sudden  suffocative 
attacks  and  dropsy. 

Percussion.     The  cardiac  dullness  extending  to  the  right  of  the 
sternum. 
24 


290  PRACTICE   OF   MEDICINE. 

Auscultation.  A  loud  blowing  murmur  associated  with  the 
second  sound  of  the  heart,  most  distinct  at  the  junction  of  the  third 
left  costal  cartilage  and  the  sternum. 

Prog"nosis.  Death  results,  sooner  or  later,  from  dropsy  and 
exhaustion. 

MITRAL   OBSTRUCTION. 

Pathological  Anatomy.  Mitral  stenosis  is  caused  by  deposits 
around  the  orifice,  the  result  of  endocarditis,  or  else  the  segments  of 
the  valves  are  "glued  together  by  their  margins,"  leaving  but  a 
funnel-shaped  opening,  the  so-called  "  button-hole "  mitral  valve. 
Vegetations  on  the  valves  lead  to  more  or  less  obstruction  of  the 
blood  current. 

Symptoms.  Hypertrophy  of  the  left  auricle  results  from  ob- 
struction of  the  mitral  orifice,  the  symptoms  of  stenosis  being  unob- 
servable  until  the  "compensation  ruptures,"  when  occur  irregular, 
small  and  feeble  pulse,  dyspnoea,  cough,  bronchorrhoea  the  result  of 
bronchial  congestion  ;  dilatation  of  the  right  side  of  the  heart,  soon 
leading  to  general  venous  stasis,  dropsy  and  death. 

Inspection.  Normal  until  auricular  hypertrophy,  when  an  undu- 
latory  impulse  is  observed  over  the  left  auricle. 

Palpation.  When  cardiac  dilatation  occurs,  a  diffused,  feeble 
and  irregular  cardiac  impulse  is  felt  near  the  xiphoid  appendix. 

Auscultation.  First  sound  normal  in  character  but  often  irregu- 
lar in  rhythm.  The  second  sound  normal.  A  blowing,  sometimes 
rasping,  sound  is  heard,  immediately  after  the  second  sound  of  the 
heart  ceases,  and  vc(\\\\^i^\2X^\y  before  the  first  sound  begins — a  pre- 
systolic murmur,  heard  most  distinctly  in  the  mitral  area,  lessening  in 
intensity  toward  the  cardiac  base.  The  cardiac  sounds  are  all  more 
or  less  enfeebled  if  cardiac  dilatation  occur. 

Prognosis.  The  prognosis  is  controlled  by  the  hypertrophy. 
Under  favorable  circumstances  mitral  stenosis  is  compatible  with  a 
long  and  rather  active  life. 

AORTIC   OBSTRUCTION. 

Pathological  Anatomy.  Stenosis  of  the  aortic  orifice  depends 
upon  the  projection  of  the  valves  inward,  and  their  becoming  rigid 
and  thickened,  or  atheromatous  or  calcareous,  so  that  they  cannot  be 
pressed  back  by  the  blood,  but  remain  constantly  in  the  current  of 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  291 

the  circulation.  Occasionally  the  valves  are  covered  with  fibrinous 
masses,  the  opening  into  the  artery  being  thus  more  or  less  com- 
pletely closed,  or  the  segments  may  be  adherent  by  their  lateral 
surfaces,  leaving  a  central  opening,  which  may  be  so  contracted  as 
to  only  permit  the  passage  of  the  smallest  article. 

Symptoins.  Hypertrophy  of  the  left  ventricle  rapidly  super- 
venes upon  aortic  stenosis.  The  pulse  is  small,  slow  and  hard.  The 
supply  of  blood  to  the  brain  is  insufficient  in  many  cases,  and  hence 
attacks  of  vertigo,  syncope  or  slight  epileptiform  seizures  occur ; 
finally,  dilatation  of  the  left  ventricle  and  incompetence  of  the  mitral 
valve  result,  with  subsequent  pulmonary  congestion,  dyspnoea  and 
general  venous  stasis,  the  pulse  soft  and  feeble. 

Palpation.  Lowered  cardiac  impulse,  strong  in  the  early  stage, 
feeble  when  dilatation  occurs. 

Percussion.  The  cardiac  dullness  is  increased  vertically,  the 
transverse  dullness  being  slightly  affected. 

Auscultation.  The  first  sound  replaced  or  associated  with  a 
harsh,  rasping  sound,  whistling  at  times,  having  its  greatest  intensity 
at  the  junction  of  the  second  right  costal  cartilage  with  the  sternum, 
transmitted  along  the  vessels  ;  the  murmur  may  sometimes  be  heard 
a  short  distance  from  the  patient. 

Usually  aortic  stenosis  is  associated  with  more  or  less  aortic  regur- 
gitation, whence  a  double  murmur  occurs,  having  its  greatest  intensity 
at  the  base  of  the  heart,  the  so-called  see-saw  murmur. 

Prognosis.  So  long  as  compensation  is  maintained  the  symp- 
toms of  aortic  stenosis  are  nil.  When  the  compensation  is  ruptured,  the 
usual  symptoms  of  dilatation,  venous  stasis  and  dropsy,  soon  follow. 

TRICUSPID   OBSTRUCTION. 

This  condition  is  one  of  the  rarest  affections  of  the  heart,  and  if  it 
ever  does  occur  with  or  following  an  attack  of  endocarditis,  the 
anatomical  changes  are  similar  to  those  of  mitral  obstruction.  This 
condition  soon  leads  to  auricular  dilatation ;  venous  stasis  rapidly 
supervenes,  associated  with  venous  pulsations  similar  to  those  de- 
scribed when  speaking  of  tricuspid  regurgitation. 

PULMONIC   OBSTRUCTION. 

Pathological  Anatomy.  Always  a  congenital  malady,  the 
changes  consisting  in    "constriction  of  the   pulmonary  artery,  un- 


292  PRACTICE   OF   MEDICINE. 

closed  foramen  ovale,  unclosed  ductus  Botalli,  stricture  at  the  ductus 
Botalli,  with  hypertrophy  of  the  right  cavity  and  frequent  association 
with  tuberculosis  of  the  lungs." 

Hypertrophy  of  the  right  ventricle  may  ensue,  the  walls  becoming 
almost  as  thick  as  those  upon  the  left  side. 

Those  in  whom  these  congenital  defects  in  the  cardiac  structure 
occur  are  otherwise  weak,  develop  slowly,  have  flabby  tissues,  soft 
bones  and  seem  poorly  nourished. 

Symptoms.  The  hypertrophy  which  often  ensues  may  keep  life 
apparently  comfortable  for  some  time,  but  sooner  or  later  "  compen- 
sation ruptures,"  when  cough,  dyspnoea,  cyanosis  and  death  occur. 

Prognosis.  The  duration  of  these  congenital  affections  is  short, 
usually  from  a  few  days  to  a  few  months  ;  although  several  well 
authenticated  cases  record  a  much  longer  duration. 

DIAGNOSIS   OF  VALVULAR   DISEASES. 

In  making  a  differential  diagnosis  between  the  various  forms  of 
valvular  diseases  of  the  heart,  strict  attention  must  be  paid  to  the 
points  of  greatest  intensity  at  which  the  several  murmurs  are  heard. 

A  inurfjiur  occurring  with  or  taking  the  place  of  the  first  sou7id  of 
the  heart — the  ventricular  systole — heard  most  distinctly  at  the  apex, 
transmitted  to  the  left  axilla,  and  to  the  inferior  angle  of  the  scapula, 
signifies  mitral  regurgitation — a  mitral  systolic  murtmtr. 

A  rnnjnnur  occurring  with  or  taking  the  place  of  \)i\^  first  sound oi  the 
heart,  with  its  point  of  greatest  intensity  at  the  xiphoid  appendix,  signi- 
fies regurgitation  at  the  tricuspid  orifice — tricuspid  systolic  7mirinur. 

A  miirjmir  heard  with  the  first  soii7id  of  the  heart,  high-pitched, 
rasping  or  grating  in  character,  with  its  point  of  intensity  greatest  at 
the  second  right  costal  cartilage,  signifies  obstruction  at  the  aortic 
orifice — a7i  aortic  systolic  i7iu7'mur. 

A  7)iuri7iur  heard  with  the  first  sound  of  the  heart,  soft  in  character, 
with  its  point  of  intensity  most  distinct  at  the  junction  of  the  third 
left  costal  cartilage  with  the  sternum,  signifies  obstruction  at  the  pul- 
monic orifice — a  puhiioiiic  systolic  7nur77iur. 

A  mur77iur  occurring  immediately  after  the  second  sound  of  the 
heart,  and  immediately  before  the  beginning  of  the  first  sound  of  the 
heart,  signifies  obstruction  at  the  mitral  orifice — a  presystolic  77iitral 
77iur77iur. 

A  murmur  heard  with  or  taking  the  place  of  the  seco7id  sound  of  the 


DISEASES    OF   THE   CIRCULATORY   SYSTEM.  293 

heart,  most  distinct  at  the  second  costal  cartilage,  to  the  right  of  the 
sternum,  and  well  transmitted  toward  the  apex  or  below,  signifies  in- 
sufficiency or  regurgitation  at  the  aortic  orifice — aji  aortic  regurgitant 
or  diastolic  7nurmur. 

Although  eight  distinct  valvular  murmurs  have  been  described  as 
occurring  in  the  heart,  those  on  the  right  side  are  of  rare  occurrence, 
and  hence  of  little  clinical  importance. 

If  a  murmitr  be  heard  with  ^h^  first  sound  of  the  heart,  it  is  almost 
certainly  aortic  obstructive  or  initral regurgitant ;  and  if  heardWx'Ca.  the 
second  sound,  it  is  probably  aortic  regurgitant.  A  presystolic  mitral 
murmur  is  also  of  comparatively  rare  occurrence,  the  force  with  which 
the  blood  passes  from  the  left  auricle  into  the  left  ventricle  being,  under 
ordinary  circumstances,  insufficient  to  excite  sonorous  vibrations. 

Functional  or  ancFinic  murmurs  may  be  confounded  with  the  various 
forms  of  valvular  disease  of  the  heart.  The  chief  points  of  distinction 
between  them  are,  that  an  anaemic  murmur,  which  is  always  heard  at 
the  base  of  the  heart,  is  always  systolic  in  time,  not  transmitted  away 
from  the  heart,  and  is  soft  in  character,  low  in  pitch,  and  of  variable 
intensity,  now  being  heard,  now  entirely  absent. 

Treatment.  There  is  no  special  plan  of  treatment  for  each  form 
of  valvular  disease.  Prof.  Da  Costa  says,  "  I  hold  that  the  precise 
valve  affected  is  not,  with  our  present  resources,  the  keynote  to  the 
treatment  of  valvular  heart  disease.  We  are  to  take  as  indications  : 
I.  The  state  of  the  heart-muscle  and  of  the  cavities.  2.  The  rhythm 
of  the  heart-action.  3.  The  condition  of  the  arteries  and  veins  and 
of  the  capillary  system.  4.  The  probable  length  of  existence  of  the 
malady,  and  its  likely  cause.  5.  The  general  health.  6.  The  second- 
ary results  of  the  cardiac  affection." 

The  important  point  to  bear  in  mind  in  the  treatment  of  valvular 
disease  of  the  heart  is  that  it  is  associated  either  with  cardiac  hyper- 
trophy or  dilatation,  and  the  treatment,  if  any  at  all  be  required, 
is  directed  toward  this  secondary  condition.  If  compensation  be 
complete,  attention  to  the  condition  of  the  bowels,  kidneys  and  diges- 
tion, with  some  general  directions  as  to  exercise,  is  all  that  is  required. 

If  the  hypertrophy  become  marked  and  excessive,  it  is  best  con- 
trolled by  either  aconitum,  veratrum  viride,  or  nitro-glycerin. 

If  dilatation  have  occurred,  the  heart  weak  and  feeble,  the  circula- 
tion impeded,  and  venous  stasis  has  followed,  digitalis,  strophanthus, 
or  sparteine  sulphate,  with  more  or  less  active  purgation,  is  indicated. 


294  PRACTICE   OF   MEDICINE. 

If  fatty  degeneration  of  the  heart  result,  the  indications  are  for  car- 
diac rest,  stimulants,  stropJuxnthus  and  attention  to  the  excretions. 

If  the  cardiac  rhythm  is  disturbed,  add  belladonjia  to  whatever 
other  plan  of  treatment  is  being  used. 

If  the  capillary  circulation  is  weak,  strophanthus  and  nitro-glycerin 
(glonoinum)  act  better  than  digitalis,  which  has  the  power  of  contract- 
ing the  arterioles. 

Any  of  the  secondary  results  of  the  valvular  affection  are  to  be 
treated  according  to  the  particular  indications. 


PALPITATION  OF  THE  HEART. 

Synonym.     Irritable  heart. 

Definition.  A  functional  disturbance  of  the  heart ;  characterized 
by  increasing  frequency  of  its  movements  and  more  or  less  irregu- 
larity of  the  rhythm,  with  a  strong  tendency  toward  hypertrophy. 

Causes.  Over-exertion,  "the  heart  strain"  of  Da  Costa;  dys- 
pepsia ;  uterine  diseases  ;  excesses  in  tea,  coffee,  tobacco,  alcohol  or 
venery  ;  moral  and  emotional  causes,  grief,  anxiety  and  fear. 

Symptoms.  Usually  palpitation  of  the  heart  has  a  sudden  onset 
after  some  one  of  the  causes  mentioned,  prcEcordial  oppression  or 
Paifi,  rapid,  tumultuous  beating,  the  impulse  being  visible  through 
the  patient's  clothing,  dyspnoea,  anxiety,  and  a  sense  of  chokijig  or 
fullness  in  the  throat,  the  recumbent  position  impossible,  vertigo, 
faintness,  flashes  of  light,  the  pulse  full  and  strong  or  feeble,  \\\^face 
flushed  or  pale,  the  patient  having  a  feeling  of  anxiety  with  a  sense 
of  impendijig  danger  and  a  fear  of  sudden  death.  These  attacks  are 
paroxysmal,  lasting  from  a  few  moments  to  several  hours,  or  a  day, 
the  patient  often  voiding  a  large  quantity  of  limpid  urine  after  the 
paroxysm  has  subsided,  when  there  is  a  strong  tendency  to  sleep. 

Diagnosis.  Irritability  of  the  heart  is  differentiated  from  the  vari- 
ous forms  of  cardiac  disease  by  the  absence  of  all  the  physical  signs 
mentioned  as  occurring  in  those  conditions. 

Prognosis.     If  early  and  properly  treated,  favorable. 

Treatment.  The  first  point  in  the  treatment  of  irritability  of  the 
heart  is  to  remove  the  cause  ;  the  next,  to  prevent  the  recurrence  of 
the  attacks  of  palpitation. 

The  majority  of  cases  do  well  by  a  combination  of  digitalis  and 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  295 

belladonjta.  Permanent  relief  is  often  afforded  by  a  combination  of 
potassii  bromidum  cin^veratruni  viride.  Chloral  \^  also  useful.  If 
the  patient  be  anaemic,  the  author  has  had  excellent  results  follow  the 
prolonged  use  of  the  elixir  ferri^  quinincB  et  strychiiince.  Locally, 
emplastrum  belladonncs  to  the  prascordium  affords  relief. 


ANGINA  PECTORIS. 

SynonjTTQ.     Neuralgia  of  the  heart. 

Definition.  Paroxysms  in  which  there  occur  sharp  cardiac  pains, 
extending  usually  into  the  left  shoulder  and  down  the  left  arm,  accom- 
panied by  a  feeling  of  constriction  of  the  thorax  and  a  strong  sense 
of  impending  death. 

Causes.  Depending  upon  the  variety,  whether  nervous  origin  or 
organic.  Often  hereditary  ;  associated  with  chronic  cardiac  changes, 
as  diseases  of  the  coronary  arteries  or  calcification  of  the  valves ;  the 
excessive  use  of  tobacco  ;  according  to  Trousseau,  it  is  a  form  of 
masked  epilepsy,  and  may  alternate  with  true  epileptic  attacks  ;  often 
associated  with  hysteria. 

Pathological  Anatomy.  Nervous  form,  "the  pathological 
changes  which  stand  in  a  causative  relation  to  the  attacks  are  those 
of  the  cardiac  plexus  of  the  phrenic  and  of  the  pneumogastric  nerves. 
Pressure  of  enlarged  lymphatics,  inflammation  of  parts  of  the  cardiac 
plexus,  with  changes  in  the  coronary  artery,  seem  to  be  most  con- 
stant." 

Organic  form,  a  disease  of  the  arteries,  ossification  and  occasion- 
ally obliteration  of  the  cardiac  arteries,  producing  cardiac  ischemia. 

Symptoms.  A  paroxysmal  affection,  the  attacks  occurring  irreg- 
ularly ;  in  the  interval  entire  absence  of  symptoms. 

"The  patient  suddenly  sits  up  in  his  bed;  with  a  cry  of  horror 
indicates  the  sense  of  pain  at  the  praecordium.  This  pain  is  of  great 
intensity,  but  is  of  a  cold  and  sickening  character ;  the  chest  is  fixed, 
the  breathing  quickened,  and  the  hand  placed  over  the  epigastrium 
finds  that  the  heart's  action  is  slight  and  enfeebled.  The  face  wears 
a  look  of  horror,  pale  and  slightly  leadened ;  a  cold  sweat  breaks  out 
upon  the  forehead ;  worse  than  the  pain  is  the  feeling  of  fearful  sick- 
ness and  depression.  The  poor  patient  gasps,  '  I  shall  die !  I  shall 
die ! '  and  sometimes  his  short  but  concentrated  sufferings  in  a  few 
moments  end  in  death." 


296  PRACTICE   OF   MEDICINE. 

The  unpleasant  sensations  of  these  patients  during  an  attack,  and 
the  nervous  disorder  associated  with  it,  slowly  bring  about  a  mental 
change.  They  are  depressed  and  gloomy,  sometimes  suicidal,  often 
developing  epilepsy. 

Diagnosis.  The  points  to  be  remembered  are  that  the  attacks 
are  always  paroxysmal,  the  patient  having  a  sense  of  coldness,  and 
frequently  a  cold  sweat,  the  heart's  action  not  increased,  the  chest 
fixed  and  the  breathing  slow. 

Prognosis.  Unfavorable,  the  patient,  sooner  or  later,  either  suc- 
cumbing during  a  paroxysm  or  from  exhaustion,  the  result  of  the 
cardiac  changes. 

Treatment.  During  the  intervals  between  the  attacks,  an  attempt 
should  be  made  to  remove  the  exciting  cause  or  diminish  its  predis- 
posing power. 

For  the  organic  form,  no  one  remedy  is  comparable  with  a  long 
course  of  potassii  iodidi,  gr.  x-xx,  three  times  daily,  as  the  frequency 
and  intensity  of  the  attacks  are  diminished  and  a  fair  number  of  cases 
are  cured,  proving  the  axiom,  "the  iodides  are  the  digitalis  of  the 
arteries." 

For  the  nervous  form,  all  violent  emotions  and  active  physical 
exercise  is  to  be  avoided,  the  diet  regulated  and  the  excretions 
watched.  Among  the  drugs  that  are  useful  are  ferrum,  arsetiiciim, 
strychnina,  phosphorus  and  zincwn.  If  the  cardiac  action  be  weak, 
use  strophatithiis.  Trousseau  urges  the  administration  of  belladonna 
in  continuous  small  doses,  on  the  ground  of  the  analogy  of  the  affec- 
tion to  epilepsy.  Quain  states  that  a  continuous  current,  the  positive 
pole  on  the  sternum  and  the  negative  pole  on  the  lower  vertebrae, 
lessens  the  severity  and  frequency  of  the  anginal  paroxysms. 

For  the  attack,  prompt  relief  follows  the  use  of  atnyl  nitris,  n\^iij, 
inhaled  at  the  instant,  or  7norphince  stilphas,  gr.  Ye-ji ,  to  which  may 
be  added  with  advantage  atropmce  sulphas,  gr.  y^g^,  hypodermically, 
or  nitro glycerin,  gr.  TUTrVir"^^-  every  three  or  four  or  five  hours.  In 
many  cases  the  use  of  gr.  ^jj^  of  this  powerful  drug,  three  or  four 
times  a  day  for  a  long  time,  lessens  not  only  the  frequency  but  the 
severity  of  the  paroxysms. 


DISEASES   OF  THE  NERVOUS  SYSTEM.  297 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


CONGESTION  OF  THE  BRAIN. 

Synonyms.     Cerebral  hyperemia  ;  cerebral  congestion. 

Definition.  An  abnormal  fullness  of  the  vessels  (capillaries)  of 
the  brain ;  active,  when  arterial  fullness  ;  passive,  when  venous  full- 
ness ;  characterized  by  headache,  vertigo,  disorders  of  the  special 
senses,  and  if  the  hyper^emia  be  decided,  convulsions. 

Causes.  Active.  Increased  cardiac  action,  the  result  of  hyper- 
trophy of  the  left  ventricle ;  general  plethora  ;  excesses  in  eating  and 
drinking ;  alcoholism  ;  sunstroke  ;  prolonged  mental  labor  ;  dimin- 
ished amount  of  arterial  blood  in  other  parts,  the  result  of  the  com- 
pression of  the  abdominal  aorta  ;  ligation  of  a  large  artery,  and  th  e 
suppression  of  an  habitual  bleeding  hemorrhoid  are  examples. 

Passive.  Dilatation  of  the  right  heart ;  pressure  upon  the  veins 
returning  the  cerebral  blood. 

Pathological  Anatomy.  The  post-7nortein  appearances  are, 
overloading  of  the  venous  sinuses  and  of  the  meningeal  vessels, 
including  the  finer  branches ;  the  pia  mater  appears  vascular  and 
opaque  ;  the  gray  7natter  of  the  convolutions  unduly  red  ;  the  convo- 
lutio7is  may  be  compressed  and  the  ventricles  contracted,  with  the 
displacement  of  a  corresponding  amount  of  cerebro-spinal  fluid. 

Long-continued  or  repeated  congestions  lead  to  enlargement  and 
tortuosity  of  all  the  vessels,  a  moist  and  slimy  condition  (oedema) 
of  the  cerebral  substance,  and  an  increase  in  the  sub-arachnoid 
fluid. 

Symptoms.  "Rush  of  blood  to  the  head"  maybe  gradual  or 
sudden  in  its  onset,  the  symptoms  aggravated  by  the  recumbent 
position.  Headache,  with  paroxysmal  neuralgic  darts,  disorders  of 
vision  and  hearing,  buzzing  in  the  ears  and  sparks  before  the  eyes, 
contracted  pupils,  vertigo,  blunted  intellect,  inability  to  concentrate 
the  mind,  irritable  temper  and  curious  hallucinations.  The  face  is 
red,  the  eyes  congested,  and  the  carotids  pulsating.  The  sleep  is  dis- 
turbed by  dreams  and  jerkings  of  the  limbs.  If  the  attack  be  sudden 
(apoplectiform),  sudden  unconsciousness  with  muscular  relaxation 
occur. 

Cerebral  hyperaemia  in  children  often  presents  alarming  symptoms, 

25 


298  PRACTICE   OF   MEDICINE. 

such  as  great  restlessness^  insomnia,  night  terrors,  gnashing  of  the 
teeth  during  sleep,  vomiting,  contraction  of  pupils  followed  hy  general 
convulsions.  Any  or  all  of  these  symptoms  may  continue  more  or 
less  marked  from  an  hour  or  two  to  a  day,  the  child  enjoying  its  usual 
health  after  a  sound  sleep,  save  some  fatigue. 

Prog"nosis.  Mild  cases  terminate  favorably  in  a  few  hours  to  a 
day  or  two,  but  show  a  strong  tendency  to  recur.  Severe  cases  (apo- 
plectiform) may  termmate  in  health,  but  usually  foretell  cerebral 
hemorrhage. 

T\i&  passive  form  is  controlled  by  the  lesions  giving  rise  to  it. 

Treatment.  Active  form.  Remove  the  cause  if  possible.  Elevate 
the  head  and  apply  cold,  either  cold  cloths  or  the  ice  cap,  at  the  same 
time  warmth  to  the  feet.  Leeches  to  the  mastoid,  or  cups  to  the  neck, 
or  in  the  apoplectiform  variety  venesection,  to  diminish  the  intercranial 
blood  pressure  ;  compression  of  the  carotids,  or  ligatures  about  the 
thighs,  have  been  recommended. 

An  active  purgative  or  an  enemata  of  water  and  vinegar  is  also 
indicated,  to  lessen  the  vascular  tension. 

In  mild  cases  the  application  of  cold  2ind  potassii  bromidiim,  gr. 
xxx-xl,  repeated,  controls  the  congestion;  extraction  ergota  fluidwn 
is  often  beneficial ;  in  more  severe  cases  any  or  all  of  the  above-men- 
tioned means,  together  with  full  doses  of  tinctura  veratri  viridis  or 
tinctitra  aconiti,  may  be  needed. 

Passive  form.     Becomes   a  part   of  the   treatment  producing  the 

hyperaemia. 

«» 

CEREBRAL  ANEMIA. 

Definition.  An  abnormal  decrease  in  the  quantity  of  blood  in  the 
cerebral  vessels ;  general,  when  the  diminished  supply  includes  all  the 
vessels  ;  partial,  when  the  diminished  supply  is  limited  in  area  ;  char- 
acterized by  pallor,  headache,  vertigo,  some  loss  of  power,  and,  rarely, 
convulsions. 

Causes.  Partial  cerebral  anaemia  results  from  obstruction  of  a 
vessel,  from  embolism  or  thrombosis.  General  cerebral  anuimia 
results  from  hemorrhages,  wasting  diseases,  during  convalescence 
from  severe  attacks  of  fevers,  sudden  shock,  feeble  cardiac  action  and 
general  anaemia. 

Pathological  Anatomy.  The  cerebral  vessels  contain  less 
blood  than   normal ;  the   brain   is  pale  and  milky  in  color,  and  on 


DISEASES   OF  THE    NERVOUS   SYSTEM.  299 

transverse  section  there  are  no  bloody  points  ;  the  ventricles  and 
perivascular  lymph  spaces  are  well  filled  with  fluid. 

In  partial  anaemia  the  local  conditions  differ  somewhat  from  the 
above. 

Symptoms.  General  anainia ;  headache,  relieved  by  the  re- 
cumbent position  ;  vertigo,  aggravated  by  exertion  ;  general  pallor 
and  anaemia,  with  attacks  oi  fainting ;  when  the  general  cerebral 
anaemia  is  sudden  and  decided,  convulsions  occur. 

Partial  an  OB  mia  ;  sudden  loss  of  power,  of  a  limited  muscular  area, 
gradually  returning  to  the  normal  condition. 

Prognosis.  Favorable  in  all  cases  save  those  the  result  of  severe 
and  repeated  hemorrhages. 

Treatm.ent.  Regulated  nourishment,  with  stimulants.  A  certain 
number  of  hours  daily  in  the  recumbent  position  is  of  advantage. 
When  a  tendency  to  attacks  or  swooning  exists,  stimulants  or  even  the 
cautious  inhalation  of  amyl  nitris  are  indicated.  To  improve  the 
quantity  or  quality  of  the  blood — 

^  .     Tinct.  ferri  chlor., rr^xv 

Acid,  phosph.  dil., IT^v 

Liq.  Arsenic!  chloridi, ITj^iij 

Syr.  limonis, 'tTLxx 

Syr.  zingiberis, q.  s.  ad  .    .  ^ij.  M. 

SiG. — Every  six  hours,  well  diluted. 
Or— 

R-     Extracti  erythroxyli  cocoae  fld., f^ss 

Vini  albifort., f  3  ss.  M, 

SiG. — One  hour  after  meals. 


CEREBRAL  THROMBOSIS  AND  EMBOLISM. 

Synonym.s.  Partial  cerebral  anaemia ;  occlusion  of  cerebral  ves- 
sels ;  cerebral  apoplexy  (?). 

Definition.  The  occlusion  of  a  cerebral  vessel,  from  the  forma- 
tion of  a  //^r^;;2/5z/.y,  or  the  presence  of  an  embolus,  thus  Z2i.ViS\x\g  ajicFviia 
of  some  portion  of  the  brain  ;  characterized  by — the  gradual,  when  the 
result  of  thrombosis,  and  the  sudden,  when  due  to  embolism — devel- 
opment of  headache,  vertigo,  disorders  of  intelligence,  with  more  or 
less  complete  insensibility  and  paralysis. 

Causes.  Thrombosis,  or  the  formation  of  a  clot  in  the  vessel — 
an  ante  mortem  coagulation — is  almost  always  the  result  of  chronic 


300  PRACTICE   OF   MEDICINE. 

endarteritis,  as  seen  in  the  aged,  together  with  a  slowing  and  weaken- 
ing of  the  blood  current.  Chronic  alcoholism  and  syphilis  are  the 
usual  causes  of  cases  occurring  in  young  adults. 

Emboli,  in  the  great  majority  of  cases,  results  from  an  endocarditis 
— cardiac  emboli ;  small  particles  of  the  exudation  are  carried  into  the 
circulation  and  are  deposited  in  the  brain.  Emboli  may  also  be 
derived  from  aortic  aneurism,  or  syphiloma  of  the  great  vessels. 

Patholog'ical  Anatomy.  The  cerebral  arteries  may  be 
obstructed  by  emboli  or  thrombi  ;  the  cerebral  veins  and  sinuses  by 
thrombi  only.  The  changes  in  the  cerebral  tissue  are  those  of  anae- 
mia of  the  part  or  parts  supplied  by  the  occluded  vessels.  The  sub- 
sequent changes  depend  upon  the  anatomy  of  the  vessels.  If  the 
obstructed  artery  has  anastomoses,  the  collateral  circulation  is  soon 
established  and  the  brain  tissue  assumes  its  normal  condition.  If,  on 
the  other  hand,  the  occluded  vessel  be  one  of  "  Cohnheim's  terminal 
arteries  " — arteries  without  anastomoses — the  blood  in  the  whole  extent 
of  the  occluded  vessel  coagulates,  thus  preventing  the  backward  flow 
of  blood  from  the  surrounding  capillaries  and  so  obstructing  collateral 
circulation,  whence  the  anaemic  tissue  dies  or  undergoes  necrobiosis, 
followed  by  yellowish-white  softening  ;  or,  if  the  vessel  beyond  the 
seat  of  the  occlusion  remains  pervious,  blood  flows  back  through  the 
capillaries  from  the  nestrest  artery  or  vein  ;  the  parts  that  a  short  time 
before  were  bloodless  now  become  deeply  engorged,  the  succeeding 
changes  in  the  vessels  permitting  diapedesis  of  the  red  blood  globules  ; 
the  tissues  which  are  undergoing  disintegration  are  colored  by  the 
red  globules,  causing  the  appearances  entitled  "red  softening,"  which 
after  some  weeks  becomes  "  yellow  softening,"  finally  changing  to 
"  white  softening,"  when  there  is  a  milky,  or  rather  creamy,  fluid 
mixed  with  masses  or  particles  of  broken-down  nerve  elements. 

The  vessel  most  commonly  occluded  is  the  left  middle  cerebral 
artery,  which  sends  branches  to  the  second  and  third  frontal  convolu- 
tions, the  anterior  and  superior  portions  of  the  three  temporal  convo- 
lutions, the  island  of  Reil,  the  parietal  convolutions,  part  of  the 
external  and  all  of  the  internal  capsule,  the  lenticular  nucleus,  and 
most  of  the  corpus  striatum, — the  motor  cejitres. 

Symptoms.  Two  distinct  modes  of  onset;  gradual,  when  the 
result  of  thrombosis  ;  sudden  or  apoplectic,   when  due  to  embolism. 

Cerebral  thrombosis.  Most  common  in  the  aged.  Persistent /ztv?^- 
ache  and  vertigo,  at  one  time  severe  and  at  another  mild.     Next, 


DISEASES   OF   THE    NERVOUS   SYSTEM.  301 

alterations  of  the  patient's  character,  irritable,  morose  and  despondent, 
with  periods  oi  absent-mindedness,  disorders  of  vision  and  impair7ne7it 
of  memory ,  speech  becoming  hesitating  and  mumbling.  Unpaired  loco- 
motiojt,  the  result  of  the  vertigo,  and  of  muscular  weakness  and 
trembling,  followed  sooner  or  later  by  hemiplegia,  which  may  be  pre- 
ceded by  sudden  insensibility  or  occur  gradually,  the  symptoms  slowly 
proceeding  to  senile  dementia  and  death  from  exhaustion  ;  or  rarely, 
the  symptoms  are  not  so  grave,  and  partial  or  complete  recovery 
occurs  after  the  hemiplegia  from  establishment  of  the  "  collateral 
circulation." 

Cerebral  embolism.  The  symptoms  are  sudden,  but  either  mild  or 
grave  in  character. 

Mild  variety :  sudden  and  severe  vertigo,  confusion  of  mind,  mus- 
cular twitchings,  usually  one-sided,  and  vomiting,  followed  by  hemi- 
plegia, most  frequently  of  the  right  side,  the  intellect  clear  but  hesi- 
tating. After  some  weeks  or  months  the  paralysis  usually  disappears 
and  recovery  is  complete. 

Grave  or  apoplectic  variety.  Sudden  headache,  vertigo,  flushing 
ox  pallor  of  \kvQface,  or  the  patient  may  utter  a  sharp  cry,  fall  to  the 
ground  with  sudden  unconsciousness  and  complete  muscular  resolution, 
followed  by  death,  or  a  gradual  return  of  consciousness  with  hemi- 
plegia, which  is  generally  right-sided,  remaining  for  several  weeks  or 
months,  or  is  persistent,  the  7nind  remaining  normal  or  enfeebled  and 
the  em,otional  nature  highly  excitable  and  the  reason  and  judgment 
clouded,  continuing  thus  for  years,  or  gradually  developing  into 
dementia,  exhaustion  and  death. 

Duration.  Thrombosis,  essentially  an  affection  of  the  elderly,  has 
a  chronic  course.  Months  or  years  may  be  occupied  with  the  various 
symptoms  until  the  phenomena  of  senile  dementia  develop. 

Embolism  is  of  sudden  onset,  and  may  be  followed  by  a  rapid 
recovery. 

Diagnosis.  Thrombosis  is  associated  with  changes  in  the  vessels, 
the  arcus  senilis  and  other  evidences  of  senile  degeneration. 

Embolism  may  be  mistaken  for  cerebral  apoplexy,  and  while  a 
positive  differentiation  cannot  always  be  made,'  the  chief  points  will 
be  considered  when  discussing  that  affection. 

Prog'nosis.  Thrombosis  is  a  perm.anent  and  progressive  condition 
in  the  majority  of  instances.     Recovery  is  a  rare  termination. 

Embolism  may  be  followed  by  a  perfect  recovery.     Usually,  how- 


302  PRACTICE   OF    MEDICINE. 

ever,  some  evidences  of  the  plugging  remain  permanently.  Death 
may  be  the  result  within  a  day  or  two,  from  the  plugging  of  a  large 
vessel,  the  patient  never  emerging  from  the  coma.  In  other  cases  the 
patient  arouses  from  the  coma,  the  hemiplegia  with  aphasia  persisting, 
and  the  case  pursues  the  usual  course  of  localized  cerebral  softening. 

Treatment.  The  indications  in  the  early  stage  of  embolism  and 
thrombosis  is  the  reestablishment  of  the  circulation  within  the  district 
deprived  of  blood-supply,  in  order  to  prevent  the  changes  incident  to 
defective  nutrition  ;  this  is  accomplished  by  means  to  strengthen  the 
heart's  action,  tonics,  perfect  rest  for  some  time  after  the  attack,  a 
plain  but  nutritious  diet,  and  attention  to  the  various  excreta. 

Prof.  Bartholow  "has  had  remarkable  results  from  the  following 
plan  of  treatment  in  thrombosis:"  Aminonii  carbonas,  gr.  x,  with 
ammonii  iodidi,  gr.  v,  three  times  a  day,  continued  for  several  months, 
"  the  object  being  dual — to  increase  the  action  of  the  heart  and  arte- 
ries and  to  effect  a  solution  of  thrombi  forming  by  maintaining  the 
alkalinity  of  the  blood." 

In  the  aged,  presenting  indications  of  degeneration,  much  benefit 
results  from  the  use  of — 

IJk  .     Liquor  potassii  arsenitis, ■n^iij-v 

Syr.  calcii  lacto-phosphat., ,^j~y-  ^• 

SiG. — After  meals. 
It  may  be  combined  with  oleiun  morrhucE  with  decided  advantage. 
For  embolism,  the  immediate  and  persistent  use  of  the  following 
may  dissolve  the  plug:  — 

li  .     Ammonii  carbonat., gt"*  v 

Liquor  ammonii  acetatis fgj-  M* 

SiG. — Tliree  or  four  times  daily. 
"  In  a  month  or  two  a  very  light  galvanic  current  (from  two  cups) 
may  be  passed  through  the  brain  in  both  directions."   (Bartholow.) 

CEREBRAL  HEMORRHAGE. 

Synonym.     Apoplexy. 

Diagnosis.  The  sudden  rupture  of  a  cerebral  vessel  and  escape 
of  blood  into  the  cerebral  tissue,  causing  pressure  and  more  or  less 
destruction  of  the  brain  substance  ;  characterized  by  sudden  uncon- 
sciousness, irregular,  noisy  respiration  and  complete  muscular  relaxa- 
tion. 


DISEASES   OF   THE    NERVOUS   SYSTEM.  303 

Causes.  Rare  under  forty  years  of  age.  The  principal  cause  is 
'disease  of  the  vessels — a  periarteritis,  resulting  in  miliary  aneurisms, 
and  especially  if  associated  with  cardiac  hypertrophy ;  hereditary 
tendency ;  Bright's  disease  ;  syphilis ;  gout.  More  frequent  in  the 
spring  and  autumn. 

Pathological  Anatomy.  The  most  common  locations  of  cere- 
bral hemorrhage  are  the  corpus  striatum  and  thalamus  opticus  ;  less 
common  the  anterior  and  middle  lobes  and  the  cerebellum  ;  next  in 
frequency  the  p07is  and  medulla  oblongata  ;  and  rarely  on  the  con- 
vexity of  the  brain,  termed  meningeal  \i^xn.oxx\\2.g&. 

When  the  hemorrhage  is  large,  the  blood  may  break  into  the  ven- 
tricles and  pass  by  the  iter  from  the  third  to  the  fourth  ventricle. 

A  recent  clot  is  dark  in  color,  and  in  consistency  a  soft,  grumous 
mass,  composed  of  coagulated  blood  and  brain  substance  in  varying 
proportions,  at  whose  centre  is  the  opening  into  the  ruptured  vessel. 
The  <r/(9/ excites  inflammation  around  it,  resulting  in  its  being  encysted, 
by  the  development  of  new  connective  tissue  from  the  neuroglia,  and 
then  gradually  absorbed,  leaving  a  cicatrix,  or  the  brain  tissue  around 
the  clot  softens  and  degenerates — localized  softening. 

Sjnnptoras.  Two  modes  of  onset,  to  wit:  with  and  without /r^- 
dromes  or  "warnings." 

Prodromes.  Headache,  vertigo,  transient  deafness  or  blindness, 
sensations  of  numbness  of  the  extremities,  with  local  palsies,  together 
with  the  constant  dread  of  an  attack. 

The  attack  begins  with  vomiting,  followed  by  either  partial  or  com- 
plete insensibility ;  respiration  slow,  irregular  and  noisy  ;  during  the 
inspiration  the  paralyzed  cheek  is  drawn  in,  and  puffed  out  in  expira- 
tion ;  pulse  slow  and  full ;  pupils  uninfluenced  by  light,  the  face 
flushed,  the  eyes  congested  and  the  carotids  throbbing ;  the  tempera- 
ture declines  below  the  normal  a  degree  or  two. 

The  muscular  system  is  profoundly  relaxed,  and  the  reflex  move- 
ments are  abolished.  The  head  and  eyes  deviate,  in  many  cases, 
toward  ih.^  affected  side  in  the  brain  or  from  the  paralyzed  side. 

If  the  unconsciousness  continues  longer  than  twenty-four  hours, 
death  is  the  usual  termination,  preceded  by  pale  face,  irregular  and 
rapid  pulse  and  respiration,  and  rise  of  temperature. 

Reaction  obtains  in  from  a  half  to  three  hours,  consciousness  re- 
turning, reflex  excitability  reviving,  associated  with  headache,  con- 


304  PRACTICE   OF   MEDICINE. 

fusion  of  mind,  and  more  or  less  paralysis  of  motion  and  sensibility 
of  one  side  of  the  body,  termed — hemiplegia. 

The  electro-excitability  of  the  paralyzed  parts  is  preserved. 

Restoration  may  be  delayed  by  inflammatory  symptoms,  the  tem- 
perature rising  to  ioi°-io4°  F.,  with  tonic  contractions  {early  rigidity) 
of  the  paralyzed  muscles  and  severe  neuralgic  pains. 

Sequelae.  Paralysis  of  the  muscles  of  the  face,  tongue,  body  and 
extremities  of  one  side,  opposite  to  the  location  of  the  hemorrhage, 
termed  unilateral  paralysis  or  right  or  left  hemiplegia. 

Paralysis  of  both  sides  of  the  body,  due  to  simultaneous  hemorrhage 
on  both  sides,  termed  bilateral  hemiplegia. 

Paralysis  oi  one  side  of  the  face  and  the  extremities  of  the  opposite 
side,  due  to  hemorrhage  into  the  pons  varolii,  termed  alternating  ox 
crossed  paralysis. 

Occasionally  tonic  contractions  occur  in  muscles  long  paralyzed, 
termed  late  rigidity,  and  is  evidence  of  a  secondary  degeneration  of 
the  nerve  fibres. 

Choreic  movements  in  paralyzed  muscles  are  termed  post-hemi- 
piegic  chorea,  due,  according  to  Charcot,  to  changes  in  the  motor 
centres. 

The  mental  powers  are  always  more  or  less  permanently  impaired, 
the  patient  irritable  and  emotional,  and  the  same  holds  good  concern- 
ing the  niemory. 

Diagnosis,  hisensibility  from  drink  differs  from  apoplexy  in  the 
following  points,  to  wit :  insensibility  is  not  so  complete,  no  drawing 
in  and  puffing  out  of  one  cheek  with  respiration,  the  pulse  frequent 
instead  of  slow,  the  pupils  influenced  by  light ;  upon  raising  both  legs 
no  difference  is  apparent  on  allowing  them  to  drop  ;  the  eyes  and  head 
are  not  turned  to  one  side,  and  lastly,  the  condition  is  ameliorated  on 
the  inhalation  of  ammonia.  I  have  satisfactorily  used  Dr.  von  Wede- 
kind's  test  for  temulence,  to  wit :  "  By  simply  pressing  on  the  supra- 
orbital notches  with  a  steadily  increasing  force  you  may,  with  certainty 
of  success,  bring  an  unconscious  alcoholic  to  his  senses,  and  thus  dif- 
ferentiate between  alcoholic  and  other  comas." 

Opium  poiso7iing  differs  from  apoplexy  by  the  gradual  approach  of 
the  coma,  and  that  the  patient  can  be  momentarily  aroused,  and  also 
by  the  absence  of  the  heavy  stertor  of  apoplexy. 

Urcemia  causes  a  coma  that  closely  resembles  apoplexy.     A  history 


DISEASES   OF  THE    NERVOlJS  SYSTEM.  305 

of  Bright's  disease  at  once  clears  up  the  case ;  again,  uraemic  coma  is 
always  preceded  by  convulsions,  and  has  a  continued  depressed  tem- 
perature. 

Cerebral  embolism  cannot  always  be  differentiated  from  apoplexy. 
We  may  suspect  cerebral  plugging,  if  the  patient  be  young  ;  if  he  be 
laboring  under  acute,  subacute  or  chronic  valvular  trouble ;  if,  within 
brief  periods,  several  incomplete  attacks  have  occurred  before  a  com- 
plete comatose  condition  obtains;  or,  if  hemiplegia  results  with  pass- 
ing or  slight  consciousness ;  or,  if  the  phenomena  are  sooner  or 
later  followed  by  cerebral  softening,  as  embolism  and  thrombosis  are 
the  most  common  causes  of  softening. 

Syncope  or  a  fainting-fit  is  of  sudden  onset,  but  being  due  to  a 
failure  of  the  circulation,  the  pulse  is  feeble,  the  face  pale,  the  respi- 
ration quiet,  and  the  duration  of  unconsciousness  short,  all  the  very 
opposite  of  an  apoplectic  attack. 

Prognosis.  If  the  patient  survive  the  immediate  effects  of  a 
cerebral  hemorrhage,  he  is  always  in  danger  of  a  new  attack,  since 
the  causes  of  the  original  attack  still  remain.  Another  attack  or  two 
is  the  usual  course,  a  fatal  termination  ultimately  occurring. 

The  hemiplegia  is  uncertain ;  a  partial  recovery  may  occur  within 
a  few  months,  or  it  may  continue  for  years.- 

Treatment.  If  there  are  prodromal  indications,  the  most  prompt 
means  of  reducing  the  intra-cranial  blood  pressure  is  by  ve7iesectio7i, 
followed  by  a  brisk  purgative  ;  if  the  patient  be  weak,  however,  leeches 
to  the  mastoid,  and  potassii  bromidum,  gr.  xl-lx,  or  extractu7n  ergota 
fiuidiim,  f^ss-j,  may  be  substituted. 

For  the  attack,  loosen  clothing,  elevate  the  head,  remove  constric- 
tions, place  in  a  cool  room,  have  perfect  quiet,  placing  the  patient 
sufficiently  on  his  side,  with  the  face  somewhat  downward,  for  the 
tongue  and  palate  and  secretions  to  fall  forward  instead  of  backward 
into  the  pharynx,  and  at  once  venesection,  cold  to  head,  a  mustard 
footbath,  and  oleum  tiglii,  gtt.  j-iij,  with  glycerinum,  gtt.  xv,  placed 
on  back  of  tongue ;  if  the  pulse  be  full  and  strong,  when  conscious- 
ness is  regained,  either  tinctura  veratri  viride  or  tinctura  aconiti 
is  indicated. 

If  during  the  attacks  ih.&face  be  pallid  and  the  pulse  irregular,  the 
patient  is  prostrated  by  the  shock  and  stiimilants  and  digitalis  are 
indicated,  with,  perhaps,  leeches  to  the  mastoid  and  an  enema  of 
terebinihina. 


306  PRACTICE   OF   MEDICINE. 

For  the  secondary  fever,  either  iinctura  aconiti  or  tinctura  veratri 
viyide  ;  for  the  headache  and  dehrium,  camphorcE  bromidian. 

For  promoting  the  absorption  of  the  clot,  keep  the  secretions  active, 
a  good  diet  and  a  course  oi  potassii  iodidiim  or  hydrargyri  chloridum 
corrosivum,  alternated  with — 

R.     Liq.  potassii  arsenit., gr.  v 

Syr.  calcii  lacto-phosph., fSU- 

Three  times  a  day. 

After  two  or  three  months  a  weak  galvanic  current  appHed  directly 
to  the  brain,  by  placing  an  electrode  on  each  mastoid  process,  pro- 
motes absorption. 

For  the  paralyzed  muscles,  the  faradic  current  applied  by  placing 
one  electrode  over  or  near  the  nerve  innervating  the  muscle  and  the 
other  over  its  belly,  acts  as  a  tonic,  preventing  wasting  ;  it  is  assisted 
by  hypodermic  injections  of  strychnifice  sulph.,  gr.  -^^  three  times  a 
week. 

ACUTE  MENINGITIS. 

Synonyms.     Cerebral  fever  ;  arachnitis. 

Definition.  An  acute  inflammation  of  the  cerebral  pia  mater  and 
arachnoid  me7nbranes  ;  characterized  by  headache,  chill,  fever,  deli- 
rium, and  followed  by  symptoms  of  general  collapse. 

Causes.  Cerebral  overwork ;  prolonged  wakefulness  ;  acute  alco- 
holism ;  exposure  to  the  sun  ;  disease  of  the  internal  ear  ;  erysipelas  ; 
secondary,to  disease  of  serous  membranes,  and  the  continued  and 
eruptive  fevers.  Most  frequent  in  early  adult  life  and  in  young  chil- 
dren, and  in  males  rather  than  females. 

Pathological  Anatomy.  The  inflammatory  changes  may  be 
limited  either  to  the  convexity  or  to  the  base  of  the  brain. 

Intense  hypercEmia  of  both  membranes,  followed  by  a  purulent  and 
fibrinous  exudation.  The  ventricles  may  be  filled  with  fluid,  com- 
pressing and  flattening  the  convolutions. 

Symptoms.     Vary  according  to  the  stages: — 

Prodromes ;  headache,  vertigo,  cerebral  vomiting,  more  or  less 
feverishness,  continuing  from  a  few  hours  to  one  or  two  days,  when 
occurs  the 

Stage  of  Invasion  ;  onset  sudden,  with  chill,  \\\g\\  fever,  io3°-io4°, 
pulse  100-I20,  face  flushed,  with  congested  eyes^  headache,  ringing  in 


DISEASES   OF  THE    NERVOUS   SYSTEM,  307 

the  ears,  photophobia,  vertigo,  the  nausea  aggravated,  and  projectile 
vomiting. 

Stage  of  Excitement ;  general  sensibility  of  the  body  increased, 
sensitiveness  to  light,  and  acuteness  of  hearing,  delirium  furious, 
often  resembling  insanity,  continual  jerking  of  the  limbs,  oscillations 
of  the  eyeballs,  twitching  of  the  muscles  of  the  face,  followed  by 
powerful  contractions  of  the  flexor  muscles,  even  to  the  extent  of 
opisthotonus,  and  in  children  convulsions.  Duration,  from  one  day 
to  a  week  or  two. 

Stage  of  Depression  or  Collapse ;  the  patient  gradually  becomes 
more  quiet ;  the  delirium  subsides,  as  well  as  the  muscular  agitation  ; 
sofnnolence  occurs,  passing  into  coma,  at  times  temporary  conscious- 
ness, coma  soon  following  again  ;  pulse  irregular  and  s\o\f,  fever  less  ; 
various  palsies,  to  wit :  strabismus,  ptosis,  pupils  uninfluenced  by  lighti 
mouth  drawn  to  one  side,  urine  and  faeces  involuntarily  discharged. 
Death  following,  either  by  convulsions  or  by  deepening  coma. 

Diag'nosis.  Cerebrospinal  fever  closely  resembles  acute  menin- 
gitis, the  points  of  distinction  between  which  are  the  first  named 
occurring  epidemically,  associated  with  marked  spinal  symptoms  and 
an  eruption. 

The  cerebral  symptojns  of  rheumatism  are  differentiated  from  idio- 
pathic meningitis  by  the  association  of  the  joint  trouble. 

Cerebral  sympto7ns  of  typhoid  and  typhus  fever  have  a  close  resem- 
blance to  idiopathic  meningitis,  and  are  only  determined  by  a  study 
of  the  clinical  history. 

In  acute  urcemia  the  face  is  turgid,  with  puffiness  of  the  eyelids  ;  in 
meningitis  the  face  is  pale  and  no  cedema ;  uraemia  has  decided  albu- 
minuria ;  it  is  slight  or  absent  in  meningitis  ;  meningitis  has  chills 
followed  by  fever  ;  ursemia  has  not. 

In  delirium  tremens  the  delirium  is  a  busy  one,  the  patient  imagin- 
ing persons  and  animals  around  him,  and  is  wild  in  his  gestures  and 
utterances ;  the  temperature  is  normal  or  subnormal,  the  skin  wet 
and  clammy.  In  meningitis  the  delirium  is  mild  but  incoherent,  the 
surface  is  hot  and  dry,  and  there  is  severe  vomiting  and  headache. 

Prog'nosis.  Not  very  favorable.  If  recognized  early  and  treated, 
a  fair  number  of  recoveries  occur,  but  it  usually  leaves  the  patient 
subject  to  attacks  of  epilepsy  or  with  a  persistent  headache. 

Treatment.     Must  be  prompt  and  energetic  from  the  onset. 

At  once,  active  purgation  by  oleum  tiglii,  gtt.  \],  glycerinum,  X(\y, 


308  PRACTICE   OF   MEDICINE. 

dropped  on  the  tongue ;  and  if  the  urinary  secretion  be  scanty,  dry 
cups  or  digitalis  poiiltices  ov^er  the  kidneys. 

In  vigorous  subjects  a  copious  vejiesection  or  leeches  applied  behind 
the  ears,  to  the  temples,  or  the  nuchal  region,  followed  by  the  appli- 
cation of  cold  to  the  head,  and  that  it  may  be  thoroughly  applied,  the 
head  should  be  shaven. 

Control  the  active  circulation  by  aconitum  in  full  doses,  frequently 
repeated,  combined  -^AxSx  potassii  bromidum,  gr.  xx-xl,  or  use  extrac- 
tiim  ergotce flitiduvi,  foss-j  every  few  hours.  The  cerebral  circulation 
may  be  markedly  influenced  by  compression  of  the  carotids. 

The  apartment  should  be  cool,  the  air  pure,  the  patient's  head 
elevated.     The  diet  should  be  nutritious  but  easy  of  assimilation. 

The  secretions  must  be  carefully  watched,  the  catheter  being  fre- 
quently used  in  the  stage  of  collapse. 

If  the  case  show  a  disposition  to  linger,  small  doses  of  hydrargyri 
chloridutn  ynite  or  potasii  iodidzim  are  of  benefit. 

Third  stage:  Free  stinndation,  nutritious  ioo^,ferri  iodidwn  and 
flying  blisters. 

PACHYMENINGITIS. 

SjTTlonyrQS.     Meningitis  ;  haematoma  of  the  dura  mater. 

Definition.  Inflammation  of  the  dtira  mater ;  when  the  external 
layer  is  primarily  involved  it  is  termed  pachymenifigitis  externa; 
when  the  internal  layer  is  primarily  involved  it  is  termed  pachymen- 
ingitis interna. 

Causes.  Pachytnetiingitis  exterria  is  a  surgical  malady,  excited 
by  fractures,  penetrating  wounds,  and  other  injuries  of  the  skull. 

Pachymeningitis  iftterna  is  due  to  blows  upon  the  head  without 
injury  to  the  skull.  A  predisposition  may  be  created  by  chronic 
alcoholism,  scurvy,  Bright's  disease  and  syphilis.  Chronic  internal 
otitis  and  suppurative  inflammation  of  the  orbit  may  cause  it,  also 
inflammation  in  the  venous  sinuses  the  result  of  a  thrombus  under- 
going suppurative  changes. 

Pathological  Anatomy.  Pachymeni?igitis  interna.  Hyper- 
aemia  of  the  membrane,  followed  by  an  exudation  which  develops 
into  a  membranous  new  formation,  containing  a  great  number  of 
vessels  of  considerable  size  but  having  very  thin  walls.  Hemor- 
rhages from  these  new  vessels  are  of  frequent  occurrence,  which 
increase  the  size  and  thickness  of  the  neo-membrane. 


DISEASES   OF  THE   NERVOUS   SYSTEM.  309 

The  usual  position  of  the  neo-membrane  or  new  formation  is  on 
the  upper  surface  of  the  hemispheres,  extending  downward  toward 
the  occipital  lobe.  The  changes  in  the  adjacent  portion  of  the  brain 
are  dependent  on  the  size  and  thickness  of  the  neo-membrane. 
Bartholow  observed  a  case  in  which  the  "cyst"  was  half  an  inch  in 
thickness  at  its  thickest  part,  and  it  depressed  the  hemisphere  corre- 
spondingly, the  convolutions  being  flattened,  the  sulci  almost  obliter- 
ated, and  the  ventricle  lessened  one-half  in  size. 

In  Pachymeningitis  syphilitica,  the  pathological  lesion  is  in  the  form 
of  gummatous  tumors  or  masses  which  may  degenerate  and  become 
either  cheesy  masses  or  be  converted  into  a  purulent-looking  fluid. 

In  old  age  the  dura  mater  becomes  thick,  cartilaginous  and  of  a 
dull  white  color.     The  sheaths  of  the  arteries  are  also  thickened. 

Symptoms.  Very  obscure  ;  principally  those  of  cerebral  pres- 
sure. Cases  of  persistent  headache,  vertigo,  photophobia,  anorexia, 
insomnia,  gradual  impairment  of  i7itellect  and  locomotion,  followed 
by  delirium,  and  convulsions  and  coma,  or  by  apoplectic  attacks  and 
paralysis ;  in  the  aged,  or  those  in  whom  some  one  of  the  causes  of 
the  affection  are  present,  an  inflammation  of  the  dura  mater  may  be 
suspected. 

Circumscribed  painful  oedema  behind  the  ear  and  less  fullness  of 
the  jugular  of  the  corresponding  side,  the  phlegmasia  alba  dolens  en 
miniature  of  Griesinger,  are  indicative  of  thrombosis  in  the  transverse 
sinus,  as  was  first  shown  by  Virchow. 

Diagnosis.  Always  problematical,  as  the  symptoms  are  masked 
and  so  obscure  that  a  positive  diagnosis  is  impossible. 

Prognosis.  Most  unfavorable  for  either  forms,  although  the  course 
of  the  malady  is  usually  slow.  Surgical  treatment  in  traumatic  cases 
offers  some  hope. 

Treatment.  Pachymeningitis  externa  is  to  be  treated  surgically. 
Trephining  is  indicated  in  some  cases.  It  is  claimed  that  benefit 
has  followed  a  thorough  course  of  potassii  iodidum.  In  the  great 
majority  of  cases,  however,  all  that  can  be  done  is  to  treat  symp- 
toms. 


310  PRACTICE   OF   MEDICINE. 

TUBERCULAR  MENINGITIS. 

Synon3mis.     Basilar  meningitis;  acute  hydrocephalus. 

Definition.  An  inflammation  of  the  membrane  of  the  brain, 
more  particularly  the  basal  pia  mater,  attended  with  or  due  to  the 
deposit  of  gray  miliary  tubercle  ;  characterized  by  gradual  decline  of 
the  bodily  and  mental  powers. 

Causes.  Most  frequently  occurs  in  children  between  two  and  six 
years  of  age,  although  numerous  cases  are  reported  occurring  between 
the  ages  of  twenty  and  thirty  years  ;  scrofulous  diathesis  ;  inherited 
diathesis.  The  "gelatinous  children  of  albuminous  parents,"  as  the 
phrase  goes,  possess  a  special  susceptibility  to  tubercular  meningitis. 

Pathological  Anatomy.  The  deposition  of  tubercle  usually 
occurs  at  the  base  of  the  brain. 

Depositions  of  grayish-white  granules,  of  a  translucent,  somewhat 
gelatinous  appearance — miliary  tubercle,  are  distributed  along  the 
vessels  of  the  pia  mater,  resulting  in  inflammation  and  the  exudation 
of  lymph,  with  the  consequent  thickening  and  opacity  of  the  mem- 
branes. 

The  cerebral  tissue  is  not  usually  involved,  although  on  section  the 
lines  indicative  of  blood-vessels  are  very  much  increased  in  number. 
The  ventricles  are  distended  by  a  clear,  or  milky,  or  even  bloody 
serum. 

Tubercular  deposits  occur  in  the  lungs,  intestines,  and,  at  times,  in 
other  organs. 

The  presence  of  the  tubercles  alone  may  give  rise  to  no  symptoms 
until  the  exudative  products  of  the  resultant  inflammation  develop. 

Symptoms.  The  advent  is  either  gradual  and  insidious,  or  with 
convulsions,  in  which  cases  the  after  progress  is  rapid. 

Prodromes :  the  child  grows  irritable,  with  loss  of  appetite,  loss  of 
flesh,  swollen  abdomen,  constipation  alternating  with  diarrhoea,  irreg- 
ular attacks  of  feverishness,  with  attacks  of  grinding  its  teeth  during 
sleep  or  sleeplessness.  Headache  occurs,  as  shown  by  the  child,  even 
when  at  play,  suddenly  stopping  and  resting  its  head  on  its  hand  or 
on  the  floor.    Duration  of  this  stage  is  from  one  week  to  a  month  or  two. 

Stage  of  excitation :  the  onset  is  rather  sudden,  with  obstinate 
vomiting,  severe  headache,  convulsions,  fever,  io2°-i03°  in  the  even- 
ing, falling  to  99°  in  the  morning,  pulse  soft  and  compressible,  with 
irregular  rhythm.     On  drawing  the  finger  nail  lightly  over  the  surface 


DISEASES   OF   THE    NERVOUS   SYSTEM.  311 

a  red  line  results,  "  the  cerebral  stain  "  of  Trousseau.  The  symptoms 
grow  progressively  worse  with  exaltation  of  the  special  and  general 
senses ;  the  least  pinch  or  even  touch  causing  exquisite  pain  ;  spas- 
modic movements  of  the  muscles,  with  contraction  and  rigidity,  at 
times  opisthotonus.     Duration  of  this  stage  is  about  two  weeks. 

Stage  of  depression  ;  the  result  of  the  pressure  of  the  exudation  ;  the 
pulse  slow  and  compressible  with  irregular  rhythm  ;  temperature  de- 
pressed ;  tendency  to  somnolence  alternating  with  quiet  delirium, 
mental  stupor,  continual  movement  of  the  fingers,  as  in  picking  up 
objects  ;  convulsions  from  time  to  time,  strabismus,  oscillation  of  the 
eyeballs,  followed  by  intervals  of  wakefulness,  when  the  headache  is 
excruciating,  causing  the  peculiar,  unearthly  shrill  cry  or  shriek,  "  the 
hydrocephalic  cry,"  associated  with  contraction  of  the  muscles  of  the 
face,  as  if  suffering  were  experienced;  finally  collapse,  occurring  with 
the  "  Cheyne-Stokes  "  respiration,  the  co7na  deepening,  followed  by 
death,  convulsions  often  ending  the  scene.  Duration,  from  a  day  or 
two  to  two  weeks. 

Diagnosis.  Acute  meningitis  and  tubercular  meningitis  have 
closely  analogous  symptoms  during  the  stage  of  excitation,  but  the  his- 
tory and  clinical  course  of  the  two  maladies  determine  the  diagnosis. 

Prognosis.  Unfavorable.  Usual  duration,  three  or  four  weeks 
after  fully  developed  prodromes.  If  ushered  in  by  convulsion  the 
duration  is  shorter. 

Treatment.  Most  unsatisfactory.  No  means  of  retarding  the 
disease.  Treat  symptoms  as  they  develop.  Blisters,  leeches,  active 
purgation,  pustulating  ointments,  potassii  iodidum  and  hydrargyrum, 
are  all  useless. 

If  the  hereditary  tendency  be  marked,  nutritious  food,  oleum 
morrhucs,  ferri  iodidum  and  gui?tina  may  somewhat  delay  the 
development  of  the  affection. 


ACUTE  HYDROCEPHALUS. 

Synonyms.     Acquired  hydrocephalus  ;  serous  apoplexy. 

Definition.  Strictly  speaking,  hydrocephalus  signifies  water  in  the 
brain  ;  but  it  is  here  restricted  to  the  presence  of  a  serous  fluid  in  the 
arachnoid  spaces,  in  the  pia  mater,  in  the  ventricles,  and  in  the  brain 
substance  (oedema) ;  characterized  by  the  more  or  less  sudden  develop- 
ment of  cerebral  excitation,  followed  by  depression  and  usually  death. 


312  PRACTICE  OF   MEDICINE. 

Causes.  Most  common  between  the  ages  of  one  and  five, 
although  it  may  occur  at  any  age.  "  The  predominance  of  the  ner- 
vous system  in  the  bodily  conformation  "  is  a  strong  predisposing 
cause.  Among  the  exciting  causes  are  unfavorable  hygienic  condi- 
tions, dentition,  eruptive  fevers,  blows  on  the  head,  mechanical  causes 
preventing  the  return  of  the  blood  from  the  vena  Galeni  and  the 
right  sinus,  compression  of  the  jugular  vein,  diseases  of  the  right 
heart,  and  Bright's  disease. 

Patholog'ical  Anatomy.  The  effusion  may  be  limited  to  the 
ventricles,  although  there  is  usually  considerable  distention  of  the 
subarachnoid  spaces  and  oedema  of  the  pia  mater  and  neighboring 
portions  of  the  brain,  whence  results  more  or  less  softening,  especially 
around  the  ventricles.  The  choroid  plexus  is  hyperaemic  and  may 
be  the  seat  of  minute  extravasations. 

Symptoms.  There  are  three  varieties  of  acute  hydrocephalus 
with  characteristic  symptoms,  to  wit :  comatose,  co7ivulsive  and  the 
ordi7iary. 

Comatose  variety,  known  also  as  "serous  apoplexy,"  begins 
abruptly  with  the  phenomena  of  apoplexy,  the  result  of  the  sudden 
effusion.  The  pressure  is  usually  so  great  on  the  medulla  oblongata 
that  it  ceases  to  functionate,  death  resulting  in  a  few  hours,  rarely 
lasting  several  days. 

Convulsive  variety,  the  result  of  Bright's  disease  or  a  general 
dropsy,  is  ushered  in  with  headache,  nausea  and  vomiting,  followed 
in  a  day  or  two  with  convulsions,  passing  into  coma,  which  usually 
terminates  fatally,  although  rarely  a  remission  may  precede  death  for 
a  day  or  two. 

Ordinary  variety,  the  most  common  in  children,  begins  with  fever- 
ishness,  headache,  vertigo,  photophobia,  restlessness,  nocturnal  deli- 
rium, insomnia,  twitching  and  spasmodic  contractions  of  the  muscles 
and  great  hyperaesthesia  of  the  skin.  Such  symptoms  continue  for 
several  days,  when  convulsions  occur,  followed  by  death,  or  a  con- 
tinuance of  the  symptoms,  followed  by  rigidity,  stupor  and  death. 

Prognosis.     Unfavorable. 

Treatment.  An  attempt  may  be  made  to  remove  the  fluid  by 
diuretics  and  full  doses  of  potassii  iodidum. 


DISEASES   OF   THE    NERVOUS   SYSTEM.  313 

CONGENITAL  HYDROCEPHALUS. 

Synonym.     Chronic  hydrocephalus  (?). 

Definition.  An  excessive  accumulation  of  the  cerebro-spinal 
fluid  — a  cerebral  dropsy — in  the  ventricles — internal  hydrocephalus, 
or  in  the  meshes  of  the  pia  mater — external  hydrocephalus,  or  in  both 
— mixed  hydrocephalus ;  characterized  by  enlargement  of  the  head 
and  more  or  less  pronounced  nervous  phenomena. 

A  disease  of  infants  or  very  young  children. 

Causes.  Imperfect  or  arrested  development  of  the  brain  or  its 
membranes.  Occurs  in  the  offspring  of  tubercular,  scrofulous  or 
syphilitic  parents.  Inflammatory  changes  in  the  ventricles  and 
ependyma. 

Pathological  Anatomy.  Enlargement  of  the  head  is  the  chief 
external  pathological  condition,  although  there  is  no  constant  ratio 
between  the  size  of  the  head  and  the  amount  of  fluid,  the  quantity 
varying  from  an  ounce  to  a  pint  or  more.  The  liquid  is  transparent, 
of  a  straw  color,  containing  a  small  amount  of  albumin  and  chloride 
of  sodium. 

If  the  quantity  of  fluid  be  small  the  ventricles  are  simply  distended, 
if  the  amount  be  large  the  optic  thalami  and  corpus  striatum  are 
depressed  and  flattened,  the  roof  of  the  ventricles  thinned  and  the 
foramen  of  Monro  is  greatly  enlarged.  The  enlargement  of  the  head 
may  occur  before  birth  and  impede  or  prevent  natural  delivery,  or 
the  head  may  be  normal  at  birth  and  increase  after.  As  enlargement 
progresses  the  bones  are  so  thinned  as  to  be  translucent,  the  fonta- 
nelles  and  sutures  are  widened,  the  lateral  portions  of  the  cranium  pro- 
ject, the  forehead  bulges  out  over  the  eyes,  and  the  orbital  plates  are 
depressed,  forcing  the  eyes  outward  and  downward,  producing  a 
variety  of  exophthalmus  ;  the  head  has  an  irregular,  triangular  shape, 
the  base  of  the  triangle  being  the  top  of  the  head.  The  scalp,  being 
stretched  by  the  pressure  within,  becomes  tense  and  thin  and  but 
scantily  covered  with  hair,  the  veins  which  ramify  in  it  are  unusually 
prominent  and  large,  and  the  entire  head  is  elastic  on  pressure,  from 
the  amount  of  liquid  beneath. 

Hilton,  in  Rest  and  Pain,  says,  "  In  almost  every  case  of  internal 

hydrocephalus  which  I  have  examined  after  death  I  found  that  this 

cerebro-spinal  opening  (between  the  fourth  ventricle  and  the  spinal 

canal)  was  so  completely  closed  that  no  cerebro-spinal  fluid  could 

26 


314  PRACTICE   OF   MEDICINE. 

escape  from  the  interior  of  the  brain  ;  and,  as  the  fluid  was  being 
constantly  secreted,  it  necessarily  accumulated  there,  and  the  occlu- 
sion formed,  to  my  mind,  the  essential  pathological  element  of  internal 
hydrocephalus." 

Symptoms.  The  increased  size  of  the  head,  with  the  emaciated 
condition  of  the  child,  who  seemingly  eats  well,  is  what  first  attracts 
the  attention.  The  head  appears  too  heavy,  the  eyes  have  a  promi- 
nent but  downward  direction,  the  face  is  devoid  of  expression,  old 
and  wrinkled,  the  voice  feeble  ;  the  mental  development  is  not  in 
comparison  with  the  age.  When  the  period  for  standing  or  walking 
arrives  the  power  is  found  wanting.  The  further  history  is  but  a 
continuation  and  exaggeration  of  this,  until  co7ividsions  occur,  which 
sooner  or  later  terminate  fatally. 

The  duration  of  congenital  hydrocephalus  is  usually  slow  but  pro- 
gressively worse.  The  majority  terminate  within  the  first  year ;  cases 
are  recorded  of  ten  and  fifteen  years'  duration. 

Diagnosis.  In  rachitis  the  volume  of  the  head  is  increased,  due 
in  part,  at  least,  to  a  deposit  of  calcareous  matter  on  the  exterior  of 
the  cranial  bones.  Rachitis  may  be  mistaken  for  hydrocephalus  in 
cases  in  which  the  amount  of  liquid  is  small.  The  differential  diag- 
nosis is  based  on  the  shape  of  the  head,  round  in  rachitis,  square  or 
triangular  or  with  prominences  in  hydrocephalus  ;  with  the  persistent 
downward  direction  of  the  eyes  and  the  elasticity  of  the  head  on 
pressure. 

Prognosis.  Unfavorable.  Arrest  of  progress  and  even  cures  are 
reported.  Spontaneous  cures  are  reported  following  the  accidental 
discharge  of  the  fluid.     But  such  reports  are  exceptional. 

Treatm.ent.  The  use  of  the  finest  aspirator  needle  to  evacuate 
the  fluid  is  fully  justifiable.  The  proper  situation  for  the  puncture  is 
the  coronal  suture,  about  an  inch  or  an  inch  and  a  half  from  the 
anterior  fontanelle.  Firm  but  gentle  compression  of  the  cranium  with 
adhesive  strips  should  be  made  during  the  escape  of  the  fluid  and 
afterward.  A  few  ounces  of  fluid  only  should  be  withdrawn  at  a  time. 
The  internal  use  of  potassii  iodiduni  is  recommended. 

All  measures  that  tend  to  promote  the  constructive  metamorphosis 
are  to  be  used. 


DISEASES   OF  THE   NERVOUS   SYSTEM.  315 

CEREBRAL  ABSCESS. 

Synonym.     Acute  encephalitis  ;  suppurative  encephalitis. 

Definition.  An  acute  suppurative  inflammation  of  the  brain 
structure,  either  localized  or  diffused,  primary  or  secondary ;  charac- 
terized by  impairment  of  intellect,  sensation  and  emotion. 

Causes,  Primary  cerebral  abscess  is  exceedingly  rare.  Pyaemia ; 
g-landers  :  embolus  from  ulcerated  endocarditis. 

Secondary  cerebral  abscesses  result  from  injuries  to  the  cerebral 
tissues,  to  wit:  apoplexy,  embolism,  thrombosis,  and  injuries  to  the 
cranial  bones. 

Pathological  Anatomy.  Abscess  of  the  brain  affects  the  left 
side  more  frequently  than  the  right.  They  are  usually  encysted  or 
inclosed  in  a  limiting  membrane.  Abscess  of  the  brain  may  be  single 
or  multiple,  varying  in  size  from  an  almond  to  an  ^Z'g. 

It  occupies  a  limited  and  well-defined  region  of  the  cerebral  tissue, 
to  wit :  either  corpora  striata,  optic  thalami,  gray  matter  of  the  cortex, 
the  cerebellum,  or  the  white  matter  of  the  hemispheres. 

"  The  initial  stage  at  the  site  of  the  abcess  is  hyperasmia.  Minute 
extravasations  take  place  (capillary  hemorrhages),  giving  to  the  in- 
flamed area  a  dark,  reddish  color,  whence  the  term  red  softening. 
Migration  of  white  corpuscles,  diapedesis  of  some  red  corpuscles  and 
exudation  of  serum  holding  albumin  and  fibre  in  solution,  occur 
simultaneously.  The  brain  tissue,  being  soft  and  easily  broken  up,  is 
rapidly  disassociated  and  its  elements  disintegrated,  and  in  a  short 
time  a  soft,  pultaceous,  red  mass  results,  which  more  and  more  as- 
sumes a  purulent  character,  becoming  first  reddish-yellow,  then  yel- 
low or  greenish-yellow,  ultimately  almost  white.  The  injury  caused 
by  an  abscess  is  not  limited  to  the  portion  of  the  brain  inflamed,  but 
the  neighboring  territory  is  in  the  condition  of  collateral  hypersemia 
and  cedema"  (Bartholow). 

Symptoms.  A  concise  description  of  the  symptoms  of  abscess 
of  the  brain  is  very  difficult,  on  account  of  the  wide  variations  de- 
pendent on  its  location,  and  also  the  difficulty  of  isolating  it  from  the 
affections  to  which  it  is  secondary. 

The  onset  varies  according  to  the  cause,  although  all  cases  are  asso- 
ciated with  headache,  irritative  fever,  persistent  and  spreading  paraly- 
sis, and  convulsions. 

If  following  apoplexy,  thrombosis,  or  emboli,  there  occurs  fever  and 


316  PRACTICE   OF   MEDICINE. 

delirium,  the  paralysis  remaining  and  spreading  with  spasmodic  con- 
tractions of  the  affected  muscles. 

Occasionally  cases  run  a  chronic  course,  the  onset  rather  insidious  ; 
dull,  persistent  headache,  changed  disposition,  peevish,  irritable,  un- 
reliable, with  decline  of  moral  sensibility  ;  easily  fatigued  by  mental 
work;  inabilityto  stand  exertion;  memory  impaired;  vertigo;  dys- 
pepsia, soon  followed  by  slight  palsies,  which  progressively  increase, 
becoming  general,  with  involuntary  discharges,  death  following  from 
exhaustion. 

Diagnosis.  A  positive  diagnosis  is  only  possible  by  a  close  study 
of  the  clinical  histor}^  as  the  symptoms  at  times  indicate  meningitis, 
cerebral  congestion,  epilepsy  or  cerebral  tumor. 

Prognosis.  The  usual  termination  is  in  death.  The  course  de- 
pends upon  the  character  and  extent  of  the  injury,  varying  from  a  few 
days  to  several  months. 

Treatment.  Surgical  treatment  has  been  attended  with  marked 
success  in  some  cases  of  abscess  of  the  brain,  the  withdrawal  of  the 
pus  being  followed  by  recovery.  For  traumatic  abscess  the  operation 
of  trephining  is  indicated.  Symptomatic  treatment  for  relief  of  the 
various  symptoms  as  they  arise. 


INTRA-CRANIAL  TUMORS. 

Synonym.     Cerebral  tumors. 

DeJBLnition.  Tumor  of  the  brain  is  either  a  growth  in  the  cere- 
bral tissue,  on  the  meninges,  or  in  the  vessels  ;  characterized  by  symp- 
toms of  pressure  upon  the  brain  structure. 

Causes.  Injuries  to  the  head;  syphilis;  changes  in  the  vessels ; 
tubercle  and  cancer  ;  hereditary. 

Pathological  Anatomy.  The  size  of  tumors  vary,  and  may 
become  as  large  as  an  orange  before  they  will  give  rise  to  symptoms. 

Tumors  of  the  brain  are  of  various  kinds,  to  wit :  vascular  tumors 
— aneurisms  ;  parasitic  tumors — cysticercus  ;  diathetic  tumors — tu- 
bercle or  syphilis  ;  accidental  tumors — fibroplastic. 

Whatever  the  character  of  growth,  it  produces  irritation  to  the  sur- 
rounding parts,  and  by  pressure,  destruction  of  the  tissues,  or  it  in- 
terferes with  the  arterial  or  venous  flow. 

Symptoms.  Those  common  to  tumors  in  general  are,  headache, 
persistent  and  increasing  in  intensity,  defects  of  vision,  even  blind- 


DISEASES   OF   THE    NERVOUS   SYSTEM.  317 

ness,  defects  of  hearing,  taste  and  of  speech,  the  result  of  paresis  of 
the  vocal  cords,  vertigo,  associated  with  nausea  and  vomiting ;  con- 
vulsions, epileptiform  in  character,  usually  limited  to  one  side  of  the 
body,  occurring  at  regular  intervals,  or  confined  to  the  eyeballs  or 
one  limb,  with  no  loss  of  consciousness ;  palsies,  beginning  first  as 
strabismus,  ptosis  and  dilatation  of  the  pupil^  of  the  facial  muscles, 
paraplegia  and  general  hemiplegia  ;  defects  of  sensibility,  to  wit : 
sensations  of  numbness,  and  coldness  in  the  limbs  and  body.  Oc- 
casionally disturbances  of  equilibrium  manifested  by  a  tendency  to 
go  backward  or  turn  to  the  right  or  left ;  intellectual  faculties  well  pre- 
served until  late  in  the  affection,  when  the  memory  becomes  impaired 
or  lost  for  certain  articles,  and  finally  a  gradually  advancing  imbecility. 

Diagnosis.  Rarely  can  a  positive  diagnosis  be  made.  The  fol- 
lowing points  will  aid :  long-continued,  persistent  headache,  without 
appreciable  cause,  epileptiform  convulsions,  unilateral,  without  loss 
of  consciousness,  difficulty  of  vision,  hearing  and  speech,  associated 
with  nausea  and  vomiting,  and  local  and  general  palsies. 

The  location  of  the  tumor  may  be  determined  by  the  more  or  less 
pronounced  character  of  certain  symptoms. 

The  diagnosis  of  the  character  of  the  growth  can  only  be  deter- 
mined by  a  close  study  of  the  history. 

Prognosis.  Unless  of  syphilitic  origin,  unfavorable  ;  but  it  is  to 
be  borne  in  mind  that  all  syphilitic  tumors  of  the  brain  do  not  have 
a  favorable  termination. 

Treatment.  Unsatisfactory.  Mostly  symptomatic.  As  benefit 
occasionally  follows  the  use  of  potassii  iodidum,  gr.  xx  three  times  a 
day,  or  ext.  ergotcBfid.,  3ss-j  three  times  a  day,  continued  until  their 
physiological  effects  are  produced,  these  remedies  should  be  used  in 
all  cases,  discontinuing  them  if  no  benefit  follow. 

The  surgical  treatm.ent  of  tumors  of  the  brain  was  given  a  great  im- 
petus from  the  report  of  the  case  operated  upon  in  the  practice  of 
Hughes-Bennett.     The  surgical  treatment  is  promising  for  the  future. 


APHASIA. 

Definition.  The  inability  to  use  spoken  language  or  give  vocal 
utterance  to  ideas. 

Ajnnesic  aphasia,  or  loss  of  the  memory  of  words  by  which  ideas 
are  expressed. 


318  PRACTICE   OF   MEDICINE. 

Ataxic  aphasia,  the  inability  to  combine  the  different  parts  of  the 
vocal  apparatus  for  vocal  expression,  although  the  memory  of  words 
still  remains,  so  that  the  afflicted  person  can  write  his  ideas  intelli- 
gently. 

Agraphia,  the  inability  to  recognize  and  make  the  signs  by  which 
ideas  are  communicated  in  written  language. 

Amnesic  agraphia,  the  inability  to  combine  the  muscular  apparatus 
— "writers'  cramp." 

Paraphasia,  the  mental  state  in  which  the  wrong  words  are  used  to 
express  the  idea. 

Paragraphia,  the  state  in  which  wrong  or  meaningless  written  signs 
are  used  to  express  the  idea. 

Pathological  Anatomy.  The  distinction  between  aphasia  and 
aphonia  must  be  clearly  determined. 

Aphasia  is  not  the  result  of  any  one  specific  lesion,  but  occurs  dur- 
ing the  course  of  several,  to  wit :  occlusion  of  certain  cerebral  vessels ; 
cerebral  hemorrhage ;  cerebral  abscess  or  softening ;  meningitis ; 
tumors  ;  mental  or  moral  causes  ;  hysteria. 

It  is  now  almost  definitely  determined  that  lesions  of  the  left  middle 
cerebral  artery,  island  of  Reil,  third  frontal  convolution,  and  parts  of 
the  corpus  striatum,  are  associated  in  the  production  of  aphasia.  The 
lesions  are  usually  upon  the  left  side  of  the  brain,  the  aphasia  being 
associated  with  right  hemiplegia. 

Symptoms.  The  degree  to  which  articulate  language  is  im- 
paired varies,  from  the  loss  of  a  few  words  to  complete  inability  to 
communicate  ideas.  The  intellect  does  not  suffer  in  proportion  to  the 
loss  of  words  ;  for,  showing  the  individual  an  article,  while  he  may 
miscall  it,  if  you  call  it  by  name  he  will  recognize  it.  This  inability 
to  convey  thoughts  is  a  source  of  great  mental  suffering,  in  some 
leading  to  a  suicidal  tendency. 

A  strange  clinical  fact  is  the  strong  tendency  to  profanity  shown 
by  aphasic  patients. 

Diagfnosis.  Aphonia,  or  loss  of  voice,  should  not  be  confounded 
with  aphasia,  or  the  inability  to  remember  words. 

Paralysis  of  the  tongue,  or  inability  to  move  this  organ,  thereby 
interfering  with  articulate  language,  should  not  be  confounded  with 
aphasia,  which,  as  a  rule,  is  not  associated  with  paralysis  of  the 
tongue. 

Prognosis.     Controlled  entirely  by  the  cause.     If  the  result  of 


DISEASES   OF   THE    NERVOUS   SYSTEM.  319 

congestion  of  the  brain  or  a  syphilitic  tumor,  the  prognosis  is  favor- 
able. If  associated  with  hemiplegia  the  clot  may  undergo  absorption, 
and  recovery  follow.  If  associated  with  softening  of  the  brain,  how- 
ever, the  disease  grows  progressively  worse. 

Treatment.  Depends  upon  the  cause,  which  must  be  energeti- 
cally treated,  as  the  aphasia  pursues  a  course  parallel  to  the  asso- 
ciated malady.  Cases  not  associated  with  cerebral  softening  have 
regained  the  memory  of  words  by  a  course  of  carefully  conducted 
speech  lessons. 

Cases  of  aphasia  of  sudden  occurrence  are  strongly  diagnostic  of 
injury  due  to  a  spicula  of  bone  if  a  history  of  a  head  wound,  or  from 
the  pressure  of  a  clot,  and  the  operation  of  trephining  will  be  of 
benefit. 

VERTIGO. 

Synonym.     Dizziness. 

Definition.  Vertigo  or  dizziness  is  a  subjective  state,  in  which 
the  individual  affected,  or  the  objects  about  him,  seem  to  be  in  rapid 
motion,  either  of  a  rotary,  circular,  or  a  to-and-fro  kind. 

Causes.  The  etiology  of  an  attack  of  vertigo  depends  upon  the 
particular  variety. 

Ocular  vertigo  results  from  the  paresis  of  one  or  more  of  the  ocular 
muscles,  eye-strain  or  astigmatism. 

Aural  or  Auditory  vertigo,  or  Mtniere  s  diseases,  results  from  disease 
of  the  semicircular  canals  and  cochlea.  Meniere's  disease  properly 
so  called,  is  a  sudden  severe  vertigo,  the  result  of  either  a  hemorrhage 
or  a  serous  or  purulent  exudation  into  the  semicircular  canals. 

Gastric  vertigo  is  the  most  common  variety,  and  results  from  either 
stomachic  or  intestinal  dyspepsia,  disordered  hepatic  function  or  consti- 
pation. "  The  mechanism  of  the  vertigo  is  complex.  There  are  two 
factors ;  one  consists  in  the  toxic  effect  of  the  imperfectly  oxidized 
materials  which  accumulate  in  the  blood  ;  the  other  is  reflex.  An 
impression  made  on  the  end  organs  of  the  pneumogastric  in  the 
stomach  is  reflected  over  the  sympathetic  ganglia."     (Bartholow.) 

Nervous  vertigo  is  associated  with  migraine,  sick  or  nervous  head- 
ache,  and  is  also  caused  by  physical  or  nervous  excesses,  also  by  the 
immoderate  use  of  tea,  coffee,  alcohol  and  tobacco.  It  is  also  a  result 
of  many  of  the  organic  diseases  of  the  brain. 

Senile  vertigo  is  the  result  of  the  disordered  cerebral  circulation 
resulting  from  changes  in  the  heart  and  vessels. 


320  PRACTICE   OF   MEDICINE. 

Symptoms.  In  all  varieties  of  vertigo  the  symptom  of  a  sensa- 
tion of  objects  moving  around  the  patie7it  or  the  patient  moving 
around  objects  which  remain  stationary  is  present  in  some  degree. 
The  attack  o{  giddiness  comes  on  suddenly,  with  an  indistinctness  of 
vision  and  slight  confusion  of  the  thoughts.  The  patient  may  fall 
unless  he  grasps  something  to  steady  himself.  Nausea  and  vomiti?ig 
and  cardiac  palpitation  with  tinnitus  aurium  are  often  associated  with 
the  vertiginous  sensations.     There  is  7io  loss  of  consciousness. 

In  the  ocular  vertigo  the  attack  is  usually  the  result  of  reading, 
writing,  sewing,  or  other  close  application  of  the  eyes,  the  ordinary 
symptoms  of  vertigo  being  preceded  by  headache,  nausea,  specks 
before  the  eyes,  and  pain  in  the  eyeballs. 

In  Meniere'' s  disease  the  vertigo  is  associated  with  serious  tinnitus 
aurium  and  the  vertiginous  sensations  being  of  various  forms,  such  as 
a  see-saw  movement,  a  gyratory  motion,  right  or  left;  a  vertical  whirl, 
or  a  sensation  of  rising  and  falling  like  unto  the  swell  of  the  ocean. 
The  symptoms  are  of  long  duration,  becoming  marked  in  paroxysms. 
The  attack  of  aggravated  vertigo  is  so  sudden  and  overwhelming  at 
times  that  the  person  is  suddenly  thrown  to  the  ground  as  if  receiv- 
ing a  blow,  associated  with  nausea  and  vomiting.  As  the  condition 
continues  the  character  of  the  individual  changes,  becoming  morose, 
irritable  and  suspicious. 

Not  all  cases  of  Meniere's  disease  become  permanent,  but  it  may 
occur  in  isolated  attacks,  the  interval  being  free  from  all  sensations. 

Gastric  vertigo  is  by  far  the  most  frequent  variety.  Persons  subject 
to  vertigo  of  this  kind  live  in  constant  dread  of  cerebral  disease, 
which  frequently  results  in  true  melancholia. 

The  vertiginous  sensations  usually  occur  during  the  course  of  well- 
marked  and  long-standing  stomach  and  intestinal  disorders,  such  as 
pain  or  oppression  after  meals,  nausea,  pyrosis,  heartburn,  frequent 
eructations  and  constipated  or  rarely  diarrhoea.  The  abdomen  is  often 
distended  with  flatus.  Great  pain  in  the  nucha  is  a  very  frequent 
occurrence.  The  attack  may  be  associated  with  either  hypera^mia  or 
anaemia  of  the  brain.  The  symptoms  are  not  constant,  but  recur  at 
intervals,  sometimes  remote,  at  others  very  close  on  each  other. 

In  nervous  vertigo  the  vertiginous  symptoms  are  usually  associated 
with  more  or  less  irritability  of  temper,  restlessness  and  insomnia. 
The  onset  is  sudden,  after  some  one  of  the  etiological  factors.  In 
megrim  there  is  headache,  nausea  and  vomiting.   This  form  of  vertigo 


DISEASES   OF  THE    NERVOUS   SYSTEM.  321 

often  precedes  or  replaces  the  epileptic  convulsion,  it  also  often  pre- 
cedes the  softening  of  the  brain. 

In  senile  vertigo  the  vertiginous  symptoms  are  the  result  of  anasmia 
of  the  brain.  The  attacks  are  developed  by  any  exertion,  often  by 
merely  assuming  the  erect  posture.  There  is  a  swimming  sensation 
in  the  head,  darkness  falls  on  the  eyes  with  a  sensation  of  chilliness 
and  prostration. 

Diag'nosis.  The  diagnosis  of  the  various  forms  of  vertigo  can 
only  be  determined  after  a  close  study  of  the  history  and  course  of 
the  attack.  The  existence  of  organic  cerebral  disease  must  always 
be  kept  in  mind  in  solving  any  case. 

Prognosis.  This  will  be  influenced  by  the  variety  of  the  vertigo. 
The  prognosis  is  favorable  in  ocular  and  gastric  vertigo.  Unless  the 
result  of  organic  disease  the  prognosis  is  good  in  nervous  vertigo. 
In  auricular  vertigo  the  prognosis  is  fair,  bui  in  genuine  Meniere's 
disease  the  prognosis  is  unfavorable,  as  it  also  is  in  senile  vertigo. 

Treatment.  For  ocular  vertigo  rest  for  the  eyes  and  properly 
adjusted  glasses. 

For  cases  of  Meniere's  disease  rest  in  the  recumbent  position  and 
the  use  of  full  doses  of  quinina  (grs.  x  to  xv)  daily  for  a  long  period, 
as  suggested  by  Charcot. 

For  gastric  vertigo  a  careful  regulation  of  the  diet.  At  the  begin- 
ning of  the  treatment  it  is  often  of  great  advantage  to  place  the 
patient  on  an  exclusively  milk  diet,  gradually  widening  the  variety  as 
improvement  occurs.  In  these  cases  a  course  of  arsenicum  is  often 
serviceable.  If  the  digestion  is  torpid,  the  use  of  iinctiira  nucis 
vornicis  is  indicated.  If  the  bowels  are  constipated,  benefit  is  obtained 
from  extractiim  cascarcB  sagradce  Jiuidutn. 

For  nervous  vertigo  the  removal  of  the  exciting  cause  and  the  use 
of  such  remedies  2.'=,  ferriim ,  qnmiiia  and  strychnina,  either  alone  or 
variously  combined. 

For  senile  vertigo,  a  highly  nutritious  but  easily  digested  diet,  the 
use  of  a  good  spiritus  frunienti  and  a  course  of  hydrargyri  chloridum 
corrosivum  or  arsenicum  with  tmctiira  ferri  chloridum. 

MIGRAINE. 
Synonyms.     Megrim  ;  hemicrania  ;  sick-headache. 
Definition.   A  unilateral  paroxysmal  pain  in  the  head,  periodical, 
accompanied  with  nausea,  often  vomiting,  intolerance  of  light  and 
27 


322  PRACTICE   OF    MEDICINE. 

soiind  and  incapability  of  mental  exertion,  the  brain  for  the  time 
being  temporarily  prostrated  and  disturbed. 

Causes.  In  the  majority  of  patients  the  nervous  predisposition  to 
migraine  is  inherited,  but  whether  inherited  or  acquired,  it  commonly 
develops  before  the  age  of  thirty. 

Among  the  many  exciting  causes  are  disturbances  of  digestion,  irri- 
tation of  the  ovaries  or  womb,  worry,  exacting  mental  labor,  sexual 
excesses  and  insufficient  sleep.  The  causes  of  many  attacks,  how- 
ever, are  wrapped  in  mystery. 

Symptoms.  Attacks  of  migraine  occur  in  irregular  paroxysms, 
the  intervals  being  free  from  pain  or  nervous  disturbance. 

For  a  day  or  two  preceding  the  paroxysm,  it  will  be  ascertained, 
on  close  questioning,  that  there  was  a  feeling  of  fatigue  without 
apparent  cause,  heaviness  over  the  eyes,  with  some  flatulency  and 
indigestion. 

The  attack  proper  is  ushered  in  by  chilliness,  nausea,  often  vomit- 
ing, yawning  and  general  muscular  sore?iess,  with  intolera?ice  of  light, 
and  noises  in  the  ears  and  incapability  for  menial  exertion  and  pain 
of  a  sharp,  shooting  character  oi  great  ijitensity  and  persistency  local- 
ized most  frequently  in  either  the  frontal,  temporal  or  occipital  regions 
of  the  left  side  ;  at  the  same  time  there  is  a  tenderness  over  the  whole 
side  of  the  head.  Rarely  the  pain  is  felt  on  the  right  side  and  still 
more  rarely  on  both  sides  at  the  same  time.  The  nausea  and  other 
digestive  symptoms  may  follow  the  onset  of  the  pain  instead  of  pre- 
ceding it. 

There  is  more  or  less  disturbance  of  the  circulation,  temperature 
and  secretions  of  the  affected  parts.  At  times  there  is  marked  con- 
traction of  the  vessels,  when  the  face  is  pale,  the  eyes  shrunken  and 
the  pupils  dilated ;  again,  the  vessels  may  be  dilated,  when  the  face 
is  flushed,  the  conjunctivae  injected  and  the  pupils  contracted. 

Motion,  sound  and  light  aggravate  the  acute  suffering. 

The  attack  may  continue  with  more  or  less  intensity  for  a  few  hours 
to  two  or  three  days,  the  average  duration  being  twenly-four  hours. 

Diagnosis.  The  symptoms  are  so  characteristic  that  an  error 
seems  impossible.  It  may,  however,  be  confounded  with  anaemic 
headache,  hyperiemic  headache,  dyspeptic  or  bilious  headache  and 
neuralgic  or  rheumatic  headache. 

Prognosis.  While  few  cases  of  true  migraine  arc  permanently 
cured,  the  affection  is  free  from  danger  to  life.     In  a  fair  number  of 


DISEASES   OF   THE    NERVOUS   SYSTEM.  323 

cases  the  susceptibility  to  attacks  declines  as  the  person  advances  in 
years,  it  being  rarely  seen  after  fifty  years. 

Treatment.  To  abort  an  attack  of  migraine  or  dispel  a  paroxysm 
after  its  onset,  two  remedies  are  almost  infallible — one  is  a  hypodermic 
injection  of  niorphi7icz  sulphas  (gr.  ^)  with  atropince  sulphas  (gr.  y^^), 
or  antipyrine  (gr.  xx)  repeated  in  an  hour  or  two  ;  a  large  experience 
with  the  latter  convinces  me  that  the  sufferings  of  those  subject  to  this 
distressing  malady  is  a  thing  of  the  past.  A  combination  for  attacks 
associated  with  contracton  of  the  vessels  is — 

R..     Potassii  bromid., gr.  xxx 

Morphinse  sulph., M^-  X 

vel 

Codeinse  sulph., gr.  j 

vel 

Tr.  opii  deodorat., Tl^xxx 

Aquae  menth.  p., ad  f^ss.  M. 

SiG. — Repeated  p.  r.  n. 

In  the  intervals  between  the  paroxysms  measures  to  improve  the 
general  system  should  be  used,  and  to  overcome  as  far  as  possible 
any  of  the  etiological  factors  in  its  production. 

"  If  the  disposition  to  the  malady  is  inherited,  the  prophylaxis  is 
very  important,  and  should  include  diet,  exercise,  clothing,  and  the 
avoidance  of  all  those  conditions  which  tend  to  develop  an  abnormal 
excitability  of  the  nervous  system.  The  best  results  have  been  ob- 
tained from  galvanization  of  the  superior  gangha  of  the  sympathetic ; 
the  positive  pole  over  the  ganglion  and  the  negative  on  the  epigas- 
trium in  the  tetanic  (contracdon  of  vessels)  form  ;  and  the  poles 
reversed  in  the  paralytic  (dilatation  of  vessels)  form."     (Bartholow.) 


ALCOHOLISM. 

Varieties.     Acute  alcoholism  ;  chronic  alcohohsm, 

Synonynis.     Acute  variety,  X.^x^ivXo.n'Cx^.',  mania-a-potu. 

Chro7iic  variety,  dehrium  tremens  ;  dipsomania  or  oinomania. 

It  would  hardly  be  correct  to  consider  these  terms  interchangeable  ; 
they  are  rather  names  applied  to  various  conditions  due  to  acute  or 
chronic  alcoholic  poisoning. 

Definition.  Alcoholism  is  the  term  used  to  designate  the  physi- 
cal and  mental  phenomena  induced  by  the  abuse  of  alcohol. 

Temulentiay    meaning   drunkenness;    mania-a-poiu    is    an    acute 


324  PRACTICE   OF   MEDICINE. 

mental  derangement,  occurring  in  those  of  strong  neurotic  tendencies  ; 
d€liriu))i  tremens  is  an  attack  of  delirium  associated  with  tremors  in 
persons  with  the  numerous  changes  resulting  from  chronic  alcoholism  ; 
dipsomania  or  oinomania,  an  alcohol  insanity  in  which  an  individual 
at  longer  or  shorter  intervals  has  paroxysms  of  alcoholic  desires, 
between  which  he  neither  wishes  nor  craves  alcohol. 

Causes.  Predisposing  causes  are  influences  arising  from  unfavor- 
able moral,  social  and  personal  conditions.     Heredity. 

Exciting  causes  are  the  immoderate  use  of  alcoholic  beverages,  of 
which  there  are  three  groups  :  i,  spirits,  or  distilled  liquors  ;  2,  wines, 
or  fermented  liquors,  and  3,  malt  liquors. 

Pathological  Anatomy.  Acute  Alcoholism.  The  brain  is  the 
seat  of  an  active  hyperiemia  ;  the  mucous  membrane  of  the  stomach 
and  duodenum  is  markedly  injected  and  covered  with  a  ropy 
mucus  slightly  tinged  with  blood,  and  the  gastric  juice  is  altered  in 
quality  and  quantity.  The  kidneys  are  also  the  seat  of  an  active 
hyperaemia. 

Chronic  Alcoholism.  In  this  condition  of  the  economy  there  are 
no  organs  or  tissues  which  do  not  present  morbid  changes.  The 
gastro-intestinal  mucous  membrane  presents  the  changes  of  chronic 
catarrhal  inflammation  ;  the  liver,  the  first  organ  to  receive  the  poison 
after  the  stomach,  presents  the  changes  of  congestion,  cirrhosis  or 
fatty  degeneration  ;  the  kidneys  show  chronic  congestion  and  often 
the  changes  incident  to  chronic  interstitial  nephritis  ;  the  muscular 
structure  of  the  heart  may  undergo  fatty  degeneration  and  the  vessels 
the  senile  changes  of  the  aged.  The  brain  structure  presents  the 
changes  of  sclerosis  in  various  stages,  and  there  may  be  chronic 
meningitis  and  pachymeningitis  with  ha^matoma.  The  nerves  are 
altered,  atrophied  and  hardened,  and  the  neuroglia,  vessels  and 
ganglion  cells  of  the  spinal  cord  show  similar  changes. 

Symptoms.  Acute  alcoholism,  resulting  from  the  use  of  a  large 
quantity  of  alcoholic  fluid,  occurs  with  symptoms  of  mild  intoxication, 
to  drunkenness  passing  to  acute  delirium  and  acute  coma.  The 
condition  begins  with  a  period  of  exhilaration,  passing  to  semi- 
delirium,  and  ending  in  an  acute  coma,  when  the  brcathini(  is  ster- 
torous, the  face  bloated  and  congested,  the  lips  swollen  and  purplish, 
the  pupils  contracted,  the  pulse  feeble  and  slow,  the  skin  cold  and 
clammy,  the  temperature  depressed  and  frequently  co7itrol  of  sphincters 
lost.     An  individual  so  affected  is  said  to  be  "  dead  drunk.'' 


DISEASES   OF  THE    NERVOUS   SYSTEM.  325 

The  cases  of  ordinary  drunkenness  do  not  often  pass  beyond  the 
stage  of  exhilaration  ending  in  a  mild  coma  or  sleep. 

Mania-a-potu,  or  acute  alcoholic  delirium,  is  the  direct  result  of 
alcoholic  excess  in  those  engaged  in  a  sudden  debauch,  or  who  have 
drunk  alcoholic  beverages  very  "  hard  "  for  a  comparatively  short 
period.  The  individuals  grow  more  and  more  excitable,  lose  all 
desire  for  food,  are  unable  to  sleep,  become  the  prey  of  horrible 
hallucinations — "the  horrors" — finally  terminating  in  mania  which 
resembles  delirium  tremens  in  all  save  the  tremor,  which  is  absent. 

Chronic  Alcoholism.  The  condition  to  which  this  term  has  been 
given  is  truly  a  disease.  It  is  the  result  of  the  continued  use  of  alco- 
holic beverages  until  one  or  more  of  the  morbid  organic  changes 
have  occurred.  These  persons  are  markedly  dyspeptic,  with  coated 
tongue,  fetid  breath  and  early  morning  vomiting,  straining  or  retch- 
ing, attended  with  much  distress.  There  is  a  gradually  developing 
muscular  tremor,  progressing  to  the  ataxic  gait,  and  insomnia.  The 
face  may  either  become  pallid,  flabby  and  bloated  with  an  imbecile 
expression,  or  swollen,  rough  and  dusky,  with  great  bladders  under 
the  eyes,  with  yellow  injected  conjunctivas.  There  is  headache, 
vertigo,  and  attacks  of  hallucinations  ;  the  memory  grows  weaker, 
the  judgment  less  accurate,  the  moral  sense  blunted  and  the  will 
power  weak  and  erratic.  These  and  many  other  symptoms  add  to 
the  distress  of  the  individual,  which  he  attempts  to  overcome  by  the 
use  of  more  and  more  of  the  poison. 

Delirium  Tremens.  In  the  majority  of  instances  delirium  results 
from  a  prolonged  debauch,  in  an  old  drinker.  It  begins  by  an  in- 
creased tremor,  insomnia,  irritable,  excitable  manner,  followed  by  the 
characteristic  hallucinations  and  illusions,  during  which  snakes  and 
all  forms  of  repulsive  reptiles  are  seen,  causing  the  most  intense  hor- 
ror and  abject  fear.  There  also  occur  illusions  of  smell  and  hearing. 
This  marked  excitement  is  followed  by  great  depression,  the  skin  is 
cold  and  clammy,  the  pulse  feeble,  the  muscular  system  weak,  the 
mind  in  a  condition  of  coma-vigil,  and  a  febrile  condition,  typhoid  in 
character,  develops. 

The  ordinary  duration  of  an  attack  of  delirium  tremens  is  about 
two  weeks,  although  death  may  occur  at  any  time  from  cardiac  failure, 
cerebral  hemorrhage,  or  alcoholic  pneumonia.  Convalescence  dates 
from  the  beginning  of  refreshing  sleep,  the  patient  awakening  with  a 
clear  mind  and  desire  for  food.     Should  the  delirium  subside,  but  the 


326  PRACTICE   OF   MEDICINE. 

patient  continue  to  mutter  and  pick  at  the  bed-clothing,  the  tongue 
become  dry  and  cracked  and  the  regurgitation  of  dark  brownish  and 
bilious  matter  occur,  the  condition  is  critical  and  an  eariy  fatal  termi- 
nation may  be  expected. 

Dipsomania  or  oinomania  is  the  inherited  mental  condition  which 
craves  the  drinking  of  intoxicating  liquors.  This  is  a  true  mental 
disease.  It  manifests  itself  in  periodical  attacks  of  excessive  indul- 
ence  in  alcoholic  drinking,  or  this  symptom  of  this  sad  disease 
may  be  replaced  by  other  irresistible  desires  of  an  impulsive  kind, 
such  as  lead  to  the  commission  and  repetition  of  various  crimes, 
the  gratification  of  other  depraved  appetites,  robbery,  or  even  homi- 
cide. 

The  paroxysms  at  first  occur  at  long  intervals,  but  gradually  the 
intervals  become  shorter  and  shorter  until  the  individual  entirely  sur- 
renders himself  to  alcoholic  and  other  excesses. 

Diagnosis.  Profound  drunkenness  or  alcoholic  coma  may  and 
often  is  confounded  with  apoplectic  and  uraemic  coma.  Von  Wede- 
kind  suggests  the  following  method  for  diagnosing  drunkenness  : 
"  By  simply  pressing  on  the  supraorbital  notches  with  a  steadily 
increasing  force  you  may,  with  certainty  of  success,  bring  an  un- 
conscious alcoholic  to  his  senses,  and  thus  differentiate  between 
alcoholic  and  other  comas." 

The  symptoms  of  chronic  alcoholism  often  bear  a  close  resem- 
blance to  the  following  maladies  :  general  paralysis,  paralysis  agitans, 
locomotor  ataxia,  cerebral  and  spinal  softening,  epilepsy,  dementia 
and  nervous  dyspepsia. 

In  individuals  whose  habits  are  secret  the  question  of  diagnosis  is 
attended  with  considerable  difficulty.  Anstie  lays  much  stress  upon 
the  importance  of  the  following  four  points,  diagnostic  of  chronic 
alcoholism :  insomnia,  morning  vomiting,  m,uscular  tretnor  and 
causeless  inc7ital  restlessness. 

Prognosis.  In  acute  alcoholism  the  prognosis  is  good  if  the 
patient  is  manageable. 

In  chronic  alcoholism  the  organic  changes  the  direct  result  of  the 
alcoholic  habit  tend  to  shorten  life  by  the  production  of  fatty  heart, 
Bright's  disease,  insanity,  impotence,  epilepsy,  melancholia  and 
organic  brain  diseases.  The  danger  in  delirium  tremens  is  heart 
failure  of  a  deepening  coma.  Acute  lobular  pneumonia  is  a  very  fatal 
complication  of  all  forms  of  alcoholism. 


DISEASES   OF   THE    NERVOUS    SYSTEM.  327 

Treatment.  The  treatment  of  a  case  of  drunkenness  requires 
no  consideration,  as  the  rapid  elimination  of  the  alcohol  soon  occurs 
if  its  ingestion  be  stopped.  Liquor  ammonii  acetatis  in  large,  frequently 
repeated  doses,  assists  the  elimination  of  the  poison. 

For  maiiia-a-potii  the  immediate  and  complete  withholding  of  alco- 
holic beverages  is  essential  for  its  successful  treatment.  If  the  stom- 
ach will  tolerate  food,  and  usually  it  will,  milk,  diluted  with  liquor 
calcis,  or  seltzer  water,  or  hot  beef  tea  strongly  seasoned  with  capsi- 
cumi,  should  be  frequently  administered,  together  with  such  cerebral 
sedatives  diSipofassu  bromiduni  and  chloral.  If  the  attack  be  associated 
with  symptoms  of  cardiac  depression,  brisk  frictions,  artificial  warmth, 
stimulating  enemata  and  hypodermic  injections  of  niorphincB  sulphas 
(gr.  ^  with  atropiiicE  stdphas  (gr.  j^q)  or  digitalis,  are  indicated.  "  If 
chloral  be  inadmissible  by  reason  of  weakness  of  the  circulation, 
paraldehyde  may  be  substituted,  in  doses  of  from  half  a  drachm  to 
one  drachm,  repeated  at  intervals  of  from  one  to  two  hours  until 
quietude  is  produced."     (J.  C.  Wilson.) 

For  the  collapse  following  a  lethal  dose  of  alcohol,  the  stomach 
should  be  immediately  emptied  by  emetics  or  the  stomach  tube  or 
pump  and  the  organ  washed  out  with  warm  water  or  coffee,  the  patient 
placed  in  the  recumbent  position  and  surrounded  with  artificial  warmth, 
hot  frictions  to  the  lower  extremities,  the  use  of  artificial  respiration 
or  the  use  of  faradism  to  the  thorax,  inhalations  of  ammonia,  hypo- 
dermic injections  of  digitalis,  strophanthus  or  atropia.  "The  flagging 
heart  may  be  stimulated  by  occasionally  tapping  the  prsecordia  with 
a  hot  spoon — Corrigan's  hammer."     (J,  C.  Wilson.) 

Chronic  Alcoholis7n.—Th.Q  combine  of  symptoms  termed  chronic 
alcoholism  are  the  direct  result  of  the  continuous  action  of  a 
single  toxic  principle,  and  no  success  of  even  a  temporary  kind  can 
be  expected  unless  the  poison  be  withdrawn.  The  rapidity  with  which 
this  can  be  accomplished  is  a  question  for  the  skill,  judgment  and 
experience  of  the  physician  to  determine  ;  the  chief  obstacle  to  its 
success  will  be  found  moral  rather  than  physical.  Next  to  the  disuse 
of  alcohol  is  the  question  of  diet.  Much  progress  will  be  made  as 
the  appetite  and  digestion  improve,  and  so  great  attention  should  be 
given  to  it.  The  general  health  will  also  be  benefited  by  fresh  air, 
exercise,  mental  occupation  and  cold  or  tepid  sponging  and  an  occa- 
sional hot  bath  at  bedtime.  For  the  combination  of  symptoms  of 
spirit  craving,  morning  vomiting,  muscular  tremor,  mental  restless- 


328  PRACTICE   OF  MEDICINE. 

ness  and  insomnia,  no  drug  is  comparable  with  strycJinincE  sulphas, 
either  hypodermically  twice  weekly  or,  what  is  preferable,  per  the 
stomach  to  secure  its  local  action  on  the  mucous  membrane.  If  the 
insomnia  be  persistent,  in  spite  of  the  foregoing  treatment,  the  tempo- 
rary use  may  be  made  of  such  remedies  as  chloral,  inorphiiia,  paralde- 
hyde, or  extractinn  lupuli7i  ethereal  (gr.  j-iij).  In  many  cases  it  is 
desirable,  for  its  mental  effect,  if  no  other,  to  administer  what  the 
patient  terms  a  substitute  for  his  alcoholic  beverages.  The  following 
is  a  good  combination  for  that  purpose  : — 

R.     Tinctune  nucis  vom., _^ss 

Tincturae  capsici, 5j 

Ex.  lupulin  rid., ^iij 

Inf.  gent,  co., ^iss,  M. 

SiG. — Dessertspoonful  three  or  four  times  daily. 

For  anaemia,  loss  of  strength,  and  mental  debility,  benefit  may 
follow  the  use  of  syrupus  hypophosphitis. 

Delirium  Tre?nens. — The  patient  should  be  isolated,  have  a  skillful, 
sensible  nurse,  the  quantity  of  alcohol  entirely  withdrawn  or  greatly 
reduced,  supplied  with  easily  digested  nutritious  diet,  and  remedies 
used  to  combat  the  excited  nervous  system.  For  this  latter  purpose 
no  one  combination  is  comparable  with  hypodermic  injections  of 
morphincB  sulphas  (gr.  X).  with  atropine?  sulphas  (gr.  xTff)>  repeated 
p.  r.  n. ;  chloral  in  the  following  combination  also  acts  well,  if  the 
stomach  be  not  too  irritable  : —  / 

R.     Chloral, "% 

Tr.  capsici, f.^ss 

Aquse  menth.  p., f^^vss.  M. 

SiG. — Talilespoonful  every  two  hours  until  sleep,  alternated  with  a 
cup  of  hot  beef  tea  to  which  has  been  added  a  bolus  of  capsicum, 
gr.  XX. 

Care  is  necessary  that  a  condition  of  coma  be  not  produced  by  the 
remedies  mentioned. 

For  depression  and  cardiac  weakness  the  internal  use  of  any  one 
of  the  following  drugs  is  serviceable:  Spiritus  chloroformi,  a7nmonii 
carbonas,  tinctura  strophanthus,  or  digitalis. 

Dipsomania. — The  management  of  these  cases  is  much  the  same 
as  has  already  been  mentioned  for  chronic  alcoholism,  although  the 
strychnina  treatment  should  be  given  the  preference. 


DISEASES   OF  THE    NERVOUS   SYSTEM.  329 

HEAT  STROKE. 

Synonyms.  Insolation  ;  sun-stroke ;  thermic  fever ;  coup-de- 
soleil ;  heat  exhaustion. 

Definition.  A  depression  of  the  vital  powers,  the  result  of 
exposure  to  excessive  heat.  The  condition  manifests  itself  as  acute 
meningitis  (rare),  heat  exhaustion  (common),  and  as  true  sun- 
stroke. 

Causes.  Exposure  to  the  influence  of  excessive  heat,  either  to 
the  direct  rays  of  the  sun  or  artificial  heat  in  confined  quarters,  or 
diffused  atmospheric  heat  without  proper  ventilation. 

Among  the  predisposing  causes,  which  act  by  lessening  the  power 
of  the  system  to  resist  the  heat,  are  great  bodily  fatigue,  overcrowding 
and  intemperance. 

Pathological  Anatomy.  The  action  of  the  heat  upon  the 
organism  is  so  sudden,  and  the  malady  so  rapid  in  its  course,  that 
structural  changes  have  not  developed.  The  left  ventricle  is  firmly 
contracted  (Wood).  The  right  heart  and  vessels  are  gorged  with 
dark  fluid  blood.  All  the  tissues  and  organs  of  the  body  are 
in  a  stage  of  great  venous  congestion.  The  blood  is  dark,  thin, 
and  either  but  feebly  alkaline  or  decidedly  acid,  and  its  power  of 
coagulability  is  destroyed.  The  post-7nortem  rigidity  is  early  and 
marked. 

Symptoms.     Depending  upon  the  variety. 

Acute  Meningitis  the  result  of  exposure  to  heat  is  similar  to  that 
due  to  other  causes. 

Heat-exhaustio7i  develops  with  a  rapid  feeling  of  weakness  and 
prostration,  the  surface  cool,  the  face  pale,  the  voice  weak,  the  pulse 
rapid  and  feeble,  the  respirations  increased,  the  vision  growing  dim 
and  indistinct,  noises  develop  in  the  ears,  the  individual,  overcome, 
becomes  partially  or  completely  unconscious.  In  some  cases  the 
attack  of  prostration  is  sudden,  the  person  falling  unconscious,  with 
perhaps  convulsions  or  tremors,  and  shrunken  features. 

Sun-stroke.  The  symptoms,  developing  suddenly,  with  or  without 
prodromata,  are,  insensibility ,  with  or  without  deliriufn,  or  convulsio?ts, 
or  paralysis,  the  surface  flushed  and  hot,  the  conjunctiva  ijijected,  the 
breathing  either  rapid  and  shallow  or  labored  and  stertorous,  lYvepulse 
quick  and  either  bounding  or  weak,  and  the  temperature  in  the  axilla 
ranging  from  105°,  to  108°,  to  110°,  with  suppression  of  all  glandular 


330  PRACTICE   OF   MEDICINE. 

action.  Death  occurring,  the  result  of  asphyxia,  or  from  a  slow  failure 
of  respiration  and  cardiac  action. 

Diagnosis.  It  is  of  great  importance,  therapeutically,  to  distin- 
guish at  once  between  attacks  of  sun-stroke  and  heat-exhaustion. 
Cases  of  sun-stroke  are  to  be  differentiated  from  cerebral  hemor- 
rhage and  alcoholic  insensibility,  for  which  purpose  the  clinical  ther- 
mometer is  indispensable. 

Prognosis.  Attacks  of  heat-exhaustion,  if  properly  and  promptly 
treated,  favorable.  The  prognosis  of  sun-stroke  or  heat-fever  is 
unfavorable  in  the  majority  of  cases,  death  resulting  in  from  half  an 
hour  to  several  hours.  Unfavorable  indications  are,  increased  tem- 
perature, cardiac  failure,  convulsions,  absent  reflexes,  followed  by 
complete  muscular  resolution. 

Favorable  indications  are,  decline  in  surface  heat  and  axillary  or 
rectal  temperature,  stronger  pulse,  increased  depth  of  respirations, 
restored  reflexes,  and  return  of  consciousness. 

Treatment.  Cases  of  heat-exhaustion  are  successfully  treated  by 
placing  the  patient  in  the  recumbent  position,  with  the  head  low,  and 
the  use  of  stimulants.  If  able  to  swallow  administer  at  once  spiritus 
vmi  gallici,  ^ss-j,  with  tinctura  opii  deodorata,  n\^xx-xxx,  to  be 
repeated  p.  r.  n. ;  if  he  be  unable  to  swallow,  the  remedies  may  be 
thrown  into  the  rectum,  ox  spiritus  frumenti  and  tinctura  digitalis  can 
be  used  hypodermically.  As  convalescence  occurs  tonic  doses  of 
quinines  sulphas  and  strycJuiiiice  sulphas  should  be  prescribed. 

For  sun-stroke,  the  indications  for  treatment  are  the  very  opposite. 
The  patient  is  in  imminent  danger  from  the  extraordinary  tempera- 
ture, and  measures  to  reduce  it  must  at  once  be  instituted.  Of  these 
none  give  such  excellent  results  as  rubbing  with  ice,  or  the  cold  bath 
or  cold  pack,  and  cold  effusions,  cold  enemata,  and  the  hypodermic 
use  of  quinince  sulphas  or  antipyrine.  The  tendency  to  subsequent 
rise  of  temperature  is  met  by  wrapping  the  patient  in  a  wet  sheet,  or 
the  repetition  of  the  hypodermics  mentioned  if  consciousness  has  not 
been  regained,  when  they  can  be  given  by  the  mouth.  If  convulsions 
and  restlessness  occur,  the  hypodermic  use  of  morphince  sulphas,  gr. 
y^-yi,  cautiously  repeated,  is  successful.  If  symptoms  of  depression 
occur,  the  stomachic,  rectal  or  hypodermic  administration  of  stimu- 
lants is  indicated. 

For  convalescence,  use  quinince  sulphas,  strychnittCB  sulphas  or 
ferrum. 


DISEASES   OF   THE    SPINAL  CORD.  331 


DISEASES  OF  THE  SPINAL  CORD. 


SPINAL  HYPEREMIA. 

Synonyms.     Special  congestion  ;  plethora  spinalis. 

Definition.  An  abnormal  fullness  of  the  vessels  of  the  meninges 
and  cord ;  active  when  arterial  hyperasmia  ;  passive  when  venous 
hyperemia  ;  characterized  by  pain  in  the  back,  with  more  or  less  pro- 
nounced disorders  of  sensation  and  locomotion. 

Causes.  Cold  and  exposure ;  arrested  menses  ;  arrest  of  habitual 
hemorrhoidal  discharge  ;  malaria;  protracted  erect  posture  ;  injuries 
to  the  back ;  certain  spinal  poisons,  as  strychnina,  picrotoxinum,  and 
alcoholic  excesses. 

Pathological  Anatomy.  Active.  The  post-mortem  appear- 
ances are  congestion  of  the  meninges  and  cord,  the  same  vessels 
supplying  both,  with  numerous  points  of  extravasation,  due  to  the  rup- 
ture of  capillary  vessels.     The  spinal  fluid  is  increased  in  amount. 

Passive.  A  general  bluish  discoloration,  owing  to  the  abnormal 
fullness  of  the  large  anastomosing  vessels  ;  the  spinal  fluid  somewhat 
increased. 

Symptoms.  Active.  Dull  pain  in  the  dorsal  or  lumbar  region, 
shooting  into  the  hips  and  thighs,  persistent  and  increased  by  pres- 
sure ;  tenderness  on  motion  ;  tingli7tg  sensations  in  the  limbs  and  feet, 
and  sometimes  in  the  hands  and  arms;  a  feeling  of  constriction 
about  the  abdomen  is  often  present,  with  rigidity  of  the  abdominal 
muscles.  Increased  reflexes,  with  disorders  of  motility,  and  when  the 
patient  is  in  the  recumbent  '^osi\\on,jerki7ig  of  the  limbs.  On  attempt- 
ing to  walk  it  is  accomplished  with  difficulty,  from  an  ijicomplete  loss 
of  power. 

If  the  upper  part  of  the  cord  be  affected,  dyspnoea  2iTid.  palpitation 
occur. 

There  often  occur  painful  priapism  and  frequent  nocturnal  emis- 
sions. 

The  above  symptoms  may  be  followed  by  a  more  or  less  pro- 
nounced temporary  depression,  the  sensation  diminished  and  the 
lower  limbs  benumbed  and  heavy,  the  movements  weak. 

The  electro-contractility  is  preserved,  and  in  many  cases  even 
increased  or  exalted. 


332  PRACTICE   OF   MEDICINE. 

Duration.  From  a  few  hours  to  several  days  ;  if  longer,  myelitis 
may  result. 

Diagnosis.  Ancrj?na  causes  more  or  less  spinal  irritability  and 
tenderness  ;  but  the  history,  pallor  and  general  weakness,  unassociated 
with  defects  of  motility  or  sensibility,  will  prevent  error. 

spinal  menijigeal  hemorrhage  is  more  sudden  in  its  onset,  its  vio- 
lence and  its  range  of  symptoms. 

Myelitis a7id spinal  meningitis\v2,v^  symptoms  in  common  with  spinal 
congestion,  which  will  be  pointed  out  when  discussing  those  affections. 

Prognosis.     Favorable,  recovery  occurring  in  three  or  four  days. 

If  the  symptoms  show  a  tendency  to  linger,  myelitis  more  or  less 
pronounced  will  ensue. 

Treatment.  Rest,  but  avoid  lying  on  the  back,  cups  or  leeches 
along  the  spine,  followed  either  by  the  iced  or  the  hot  douche,  or  hot 
sponges,  with  active  purgation,  to  diminish  the  blood  pressure. 

If  the  result  of  suddenly  arrested  perspiration,  pilocarpus.  If  fol- 
lowing suddenly  arrested  menses,  aconitinn.  If  associated  with  an 
active  circulation,  ^^/^^.y/z  bromidum  ox  fiuidwn  gelsemii  extractum, 
TT\^v,  every  four  hours,  or  extractwn  ergotce  fluidM77i,  f^ss-j,  repeated 
p.  r.  n. ;  in  all  cases  active  purgation. 

For  the  passive  form,  treating  the  cause,  ergota,  digitalis,  tonics  and 
purgatives. 

SPINAL  MENINGITIS. 

Synonym.     Leptomeningitis  spinalis. 

Definition.  Inflammation  of  the  arachnoid  and  pia  mater  mem- 
branes of  the  spinal  cord,  either  acute,  subacute  or  chronic  ;  charac- 
terized by  pain  in  the  back,  rigidity  of  the  muscles,  disorders  of 
motility  and  sensibility.     It  may  be  acute  or  chronic. 

Causes.  Exposure  to  cold  and  dampness;  injuries  to  the  verte- 
brae or  membranes  ;  rheumatism;  puerperal  fever  ;  syphilis. 

Pathological  Anatomy.  Acute.  Hyperaemia  of  the  mem- 
branes, with  swelling  of  the  tissues,  the  result  of  serous  infiltration 
followed  by  purulent  and  fibrinous  exudations.  The  roots  of  the 
spinal  nerves  are  covered  with  exudation,  and  are  swollen  and  soft. 
The  cord  proper  is  more  or  less  congested  and  oedematous. 

Chrofiic.  Adhesions  of  the  membranes,  with  more  less  accumu- 
lation of  fluid,  resulting  in  atrophic  degeneration  of  the  cord  from 
pressure. 


DISEASES   OF   THE   SPINAL   CORD.  333 

Symptoms.  Although  an  inflammatory  affection,  yet  its  onset 
is  usually  subacute,  the  febrile  reaction  being  moderate,  with  intense 
boring  pain  in  the  back,  aggravated  by  motion,  rigidity  of  the  spine 
and  a  sense  oi  constriction  around  the  body,  "  the  girdle."  Spasmodic 
contractions  of  the  muscles  enervated  by  the  nerves  originating  at  the 
seat  of  the  lesion,  with  inability  to  straighten  the  limbs.  If  the  lower 
part  of  the  spinal  membranes  are  the  seat,  there  occur  retention  of 
urine  and  constipation  ;  if  upper  part,  dysphagia,  dyspncea  and  feeble 
heart.  The  muscular  contractions  are  excited  or  increased  by  motion, 
but  uninfluenced  by  pressure.  Reflex  inovejnents  are  not  abolished. 
The  rigidity  and  spasmodic  contraction  of  the  muscles  are  followed 
by  paralysis  more  or  less  complete,  death  following  from  paralysis  of 
the  muscles  of  respiration. 

If  the  inflammation  extend  to  the  medulla,  the  above  symptoms  are 
associated  with  disorders  of  speech,  vomiting  and  delirium. 

Electro-contractility  \Qsstne.d.  or  absent,  both  as  to  motility  and  sen- 
sibility, in  the  affected  parts. 

Chronic  form  succeeds  to  the  acute  or  originates  spontaneously, 
and  presents  the  same  form  and  order  of  symptoms — excitation  and 
depression. 

Diagnosis.  The  points  of  importance  are,  deep,  boring  pain  in 
the  back,  aggravated  by  motion  but  not  by  pressure,  with  spasmodic 
contraction  of  the  m^uscles  followed  by  paralysis. 

Myelitis  will  be  differentiated  from  spinal  meningitis  when  discuss- 
ing that  affection. 

Tetanus  may  be  confounded  with  spinal  meningitis.  The  points  of 
distinction  are:  in  the  former  occur  early  trismus  with  rhythmical 
spasms  excited  by  irritation  of  the  skin,  whereas  irritation  of  the 
skin  does  not  in  spinal  meningitis  produce  muscular  contractions,  but 
movements  of  the  limbs  does  do  so ;  progressively  increasing  and  not 
associated  with  fever. 

Prognosis.  Grave.  Death  is  either  sudden,  from  paralysis  of  the 
respiration  and  of  the  heart,  or  gradual,  the  result  of  exhaustion. 

Critical  discharges,  such  as  profuse  perspiration,  urinary  flow  or 
epistaxis  occur  and  are  followed  by  rapid  recovery.  Cases  recovering 
may  have  more  or  less  pronounced  partial  or  complete  paralysis. 

Treatment.  Rest  in  bed,  upon  the  side  or  face.  Cups  or  leeches 
along  the  spine,  followed  by  ice,  the  hot  douche,  hot  sponges,  or  mus- 
tard.    Active  purgation. 


334  PRACTICE   OF   MEDICINE. 

■  To  reduce  the  amount  of  blood  in  the  vessels  of  the  cord,  aco7iitu7n 
and  ergota  combined  with  an  opium  impression.  When  paralysis 
(depression)  occurs,  quinmce  sulphas,  gx.  iij,  combined  with  ext.  bella- 
donncE  alcoholic,  gr.  X.  three  times  a  day,  ox  potassii  iodidiim,  gr. 
xx-xxx,  three  times  a  day,  with  flying  blisters  along  the  spine.  If  the 
paralysis  still  persist,  a  hydrargyrum  impression  often  benefits. 

For  paralysis,  \.\\t  galvanic  ciirrefit  to  the  spine  and  nerve  trunks, 
and  the  faradic  current  to  the  affected  muscles,  with  the  deep  injec- 
tion of  strychnina  and  the  use  of  massage. 

PACHYMENINGITIS  SPINALIS. 

Synonyms.  Pachymeningitis  spinalis  interna ;  hypertrophic 
pachymeningitis ;  pseudo-membranous  pachymeningitis. 

Definition.  An  inflammation  of  the  spinal  dura  mater  ;  charac- 
terized by  violent  pains  in  the  head,  neck,  shoulders  and  arms,  fol- 
lowed by  paralysis  of  the  upper  extremities. 

Causes.  Exposure  to  cold  and  damp;  alcoholism;  syphilis; 
gout ;  injuries. 

Pathological  Anatomy.  Hypertrophic  pachymefiingitis  is 
characterized  by  an  exudation  upon  the  inner  surface  of  the  dura 
mater,  which  gradually  solidifies  into  a  layer  of  compact  connective 
tissue,  which  presses  upon  the  spinal  cord  and  nerves,  producing  a 
myelitis  and  an  atrophic  neuritis,  resulting  in  muscular  atrophy. 

The  most  frequent  seat  of  this  form  of  the  affection  is  the  cervical 
region,  as  first  demonstrated  by  Charcot,  whence  the  term  cervical 
hypertrophic  pachymeningitis. 

In  the  pseudo-fnetnbranous  form  a  membranous  exudation  also 
occurs,  in  which  large  numbers  of  blood-vessels  develop  and  rupture, 
the  hemorrhagic  extravasations  forming  a  cyst — ha^matoma — which 
causes  pressure  on  the  cord  and  nerves. 

Symptoms.  The  onset  is  slow  and  gradual,  with  irregular  chills 
2iX\d  feverishness,  violent  pains  in  the  head,  neck,  shoulders  and  arms, 
continuous  but  subject  to  exacerbations,  and  associated  with  2i  pain- 
ful cojistrictiofi  of  the  upper  thorax.  These  symptoms  may  continue 
off  and  on  for  several  months,  when  the  muscles  of  the  painful  parts 
begin  to  atrophy,  followed  by  spasmodic  contraction  and  paralysis. 

The  general  health  deteriorates  with  the  progress  of  the  muscular 
symptoms. 

The  electro-contractility  is  lost. 


DISEASES   OF  THE   SPINAL   CORD.  335 

Prognosis.  If  early  recognized  and  promptly  treated,  the  hyper- 
trophic form  may  be  cured. 

Treatment.  Rest;  nutritious  diet;  olewn  morrhiKE  and  the 
hypophosphites ;  large  doses  oi  potassii  iodidujn,  and  repeated  but 
systematic  counter- irritation. 


ACUTE  MYELITIS. 

Definition.  An  inflammation  affecting  the  substance  of  the  spinal 
cord,  which  may  be  limited  to  the  gray  or  white  matter,  and  involve 
the  whole  or  isolated  portions  of  the  cord.  When  lh.Qgray  matter  alone 
is  inflamed,  it  is  termed  central  myelitis ;  when  the  white  matter  and 
the  meninges,  it  is  termed  cortical  myelitis  ;  it  may  be  ascending,  de- 
scending or  transverse  in  its  extension.  The  disease  is  characterized 
by  more  or  less  sudden  and  complete  loss  of  motion  and  sensation. 

Causes.  Following  spinal  meningitis  ;  exposure  to  cold  and  damp; 
injuries  to  the  vertebras ;  prolonged  functional  activity  of  the  cord ; 
typhus  fever  ;  rheumatism  ;  syphilis  ;  puerperal  fever,  or  during  the 
course  of  the  exanthemata ;  arsenical  or  mercurial  poisoning. 

Pathological  Anatomy.  Intense  hyperaemia  of  the  substance 
of  the  cord,  with  extravasations,  giving  the  tissues  a  reddish-brown  or 
chocolate  tint,  and  also  serous  transudations,  resulting  in  softening  of 
the  structure  of  the  cord,  the  color  changing  to  yellow  and  white,  the 
nerve  elements  undergoing  fatty  degeneration,  presenting  the  appear- 
ance and  consistency  of  cream.  The  membranes  also  undergo  more 
or  less  change. 

Symptoms.  The  severity  of  the  symptoms  depends  upon  the 
extent  and  location  of  the  inflammation. 

The  onset  is  usually  sudden,  with  a  chill,  fever,  lo-^ ,  freque7it piclse, 
with  alterations  in  sensibility  attd  motility,  to  wit :  paiti  in  the  back, 
aggravated  by  touch  and  by  heat  and  cold,  with  sensations  of  formi- 
cation ("pins  and  needles"),  the  limb  feeling  as  if  asleep,  or  else 
complete  ancEthesia,  associated  with  severe  ?teuralgic  pains. 

The  distinction  between  ancEstkesia,  insensibility  to  touch,  and 
analgesia,  insensibility  to  pain,  must  be  clearly  determined. 

A  sensation  oi  constriction  around  the  body  and  limbs,  as  if  encircled 
by  a  tight  cord,  "the  girdle  pains ;  "  rapidly  developing  paraplegia, 
complete  in  a  few  hours,  with  involuntary  discharges.  The  reflex 
functions  are  usually  abolished,  as  seen  by  attempting  to  cause  move- 


336  PRACTICE   OF   MEDICINE. 

ment  of  the  limbs  by  tickling  the  feet  or  by  striking  the  patella  ten- 
don ;  rarely  are  they  diminished,  very  rarely  exaggerated.  The  tem- 
perature of  the  affected  limbs  is  lowered  three  or  four  degrees. 

Sloughs  and  bedsores  and  muscular  atrophy  result  if  the  anterior 
cornucC — the  trophic  centres — are  affected. 

The  above  symptoms  oi  loss  of  motion  and  sensibility  are  associated 
with  more  or  less  pronounced  vomiting,  hepatic  disorders,  irregularity 
of  the  heart,  dyspnoea,  dysphagia,  apncea  and  painful  priapisms.  The 
urine  is  markedly  alkaline  in  reaction. 

Among  the  late  manifestations  are  shooting  pains  and  spasmodic 
twitchings  or  co7itraciions  of  one  or  all  of  the  muscles  of  the  paralyzed 
parts. 

The  electro-contractility  is  abolished  in  the  paralyzed  parts. 

Diagnosis.  Acute  spinal  meningitis  is  distinguished  from  acute 
myelitis  by  severe  pains,  increased  by  pressure,  with  muscular  con- 
tractions increased  by  motion,  followed  by  paralysis  much  less  pro- 
found than  the  paraplegia  of  myelitis ;  in  spinal  meningitis  there 
exists  cutaneous  and  muscular  hyperaesthesia,  which  is  absent  in 
myelitis. 

Congestion  of  the  spinal  cord  vs>  characterized  by  the  mild  character 
and  short  duration  of  all  the  symptoms. 

Hemorrhage  in  the  spinal  cafial  is  abrupt,  with  irritative  symp- 
toms, slight  paralysis,  preserved  reflexes  and  electro-contractility. 

The  principal  diagnostic  points  of  acute  myelitis  are  the  "  girdle  " 
around  the  limbs  or  body,  rapid  and  complete  paraplegia,  lowered 
temperature  in  the  affected  parts,  early  and  persistent  sloughing 
(bedsores)  and  alkaline  urine. 

Prognosis.     Varies  according  to  the  location  of  the  lesion. 

If  the  paralysis  is  of  the  ascending  variety,  death  occurs  within  a 
few  days,  from  paralysis  of  the  muscles  of  respiration. 

If  the  trophic  centre  is  affected,  there  occur  bedsores,  intense  pylo- 
nephritis  and  cystitis  and  changes  in  the  joints  ;  death  from  exhaus- 
tion, in  several  weeks. 

Central  myelitis,  or  inflammation  of  ihc  gray  matter,  is  rapid  in  its 
progress,  death  occurring  in  a  week  or  two. 

The  morbid  process  may  be  arrested  and  the  general  health  restored, 
but  some  spinal  symptoms  will  persist. 

Treatment.  Absolute  rest  is  essential  to  even  secure  a  palliation 
of  the  symptoms. 


DISEASES    OF   THE   SPINAL   CORD.  337 

Locally,  considerable  relief  follows  the  use  of  hot-water  bags  or 
sponges  dipped  in  Jcot  water  and  applied  along  the  spine  every  few 
hours. 

The  remedies  most  strongly  recommended  are  :  digitalis,  ergota, 
belladonna,  bromides,  cimicifiiga,  and  qiiini7ia^  although  I  have  never 
observed  a  cure  with  any  plan  of  medication,  after  it  was  fairly  estab- 
lished, save  those  due  to  syphilis,  by  large  doses  of  potassii  iodidmn. 


INFANTILE  SPINAL  PARALYSIS. 

Synonyms.  Poliomyelitis  anterior  acuta  ;  essential  paralysis  of 
children. 

Definition.  A  rapidly  developed  inflammation  of  the  anterior 
horns  of  the  gray  matter  of  the  cord,  occurring  suddenly  in  children, 
at  times  in  adults — acute  spinal  paralysis  of  adults  ; — characterized 
by  mild  fever,  muscular  tremors  and  twitchings,  and  paralysis  of 
groups  of  muscles. 

Causes.  Essentially  a  disease  of  early  life — the  second  month  to 
the  third  or  fourth  year.  The  fact  of  its  having  occurred  in  adults 
must  be  borne  in  mind.  Cold  and  damp  ;  dentition  (?) ;  injuries  to 
the  spine ;  developed  during  convalescence  from  the  acute  exanthe- 
mata. 

Patholog'ical  Anatomy.  The  early  changes  are :  medullary 
hyperasmia,  vascular  exudation  and  inflammatory  softening,  although 
the  naked  eye  may  not  recognize  any  changes.  Microscopical  exam- 
ination reveals  inflammatory  softening  of  the  anterior  horns  of  the 
gray  matter.  Among  other  constant  lesions  are  atrophic  degeneration 
of  the  multipolar  ganglion  cells  and  of  the  anterior  nerve  roots. 

The  changes  noted  as  occurring  in  the  cord  are  usually  limited  to 
the  dorso-lumbar  and  cervical  enlargements. 

As  a  direct  result  of  the  changes  in  the  trophic  cejitre  and  the  nerve 
degeneration  of  the  muscular  flbres  supplied,  there  ensue  changes  in 
the  bones  and  joints,  leading  to  great  deformities. 

Symptoms.  The  onset  of  the  affection  varies  ;  it  is  usually  sud- 
den, with  an  attack  of  mild  fever  of  a  remittent  type,  of  a  few  days' 
duration,  on  recovery  from  which  it  is  noticed  that  the  child  is  para- 
lyzed.    Rarely  the  paralysis  may  be  preceded  by  convulsions. 

The  paralysis  may  affect  both  arms  and  both  legs,  the  legs  alone, 
or  only  one  of  the  four  extremities ;    it  may,  but  very  rarely,  be  a 
28 


338  PRACTICE   OF   MEDICINE. 

hemiplegia.  The  bladder  and  rectum  are  not  affected,  nor  can  an- 
iEsthesia  or  numbness  be  detected.  The  temperature  of  the  paralyzed 
limb  is  low  and  the  appearance  cyanosed.  After  a  few  days  there  is 
a  slight  improvement  in  the  paralyzed  parts,  although  the  muscles 
show  a  rapid  wasting,  which  is  progressive  until  all  muscular  tissue  is 
gone. 

The  reflex  jnovevtents  are  vnpaired  or  abolished. 

The  electro-contractility  by  the  faradic  current  is  abolished  in  the 
paralyzed  parts. 

With  \.\\Q  galvanic  or  constant  current  the  "  reactions  of  degenera- 
tion" are  developed.  To  fully  understand  the  meaning  of  this  term 
a  knowledge  of  the  normal  electrical  reaction  is  necessary. 

The  normal  formulae  for  the  production  of  muscular  contraction  in 
the  physiological  state  are  as  follows,  the  strength  of  the  current  being 
barely  capable  of  causing  fair  contractions  : — 

First.  The  most  effective  contractions  are  produced  by  the  cathode 
{negative)  pole  on  closing  the  circuit. 

Second.  The  second  most  effective  are  produced  by  the  a7tode  {post' 
live)  pole  on  closing  the  circuit. 

Third.  The  next  most  effective  is  by  the  anode  pole  on  opening  the 
circuit. 

Fourth.  Cathode  pole  contractions  on  opening  circuit  are  rarely 
seen  in  the  physiological  state. 

The  "reactions  of  degeneration  "  are  shown  by  any  reversal  of  the 
regular  formulae,  to  wit:  if  the  anodal  closure  shows  stronger  contrac- 
tions than  cathodal  closure ;  still  greater  degeneration  is  shown  if 
anodal  openi?tg  contractions  are  stronger  than  either  of  the  above ; 
and  almost  complete  degeneration  is  shown  by  the  complete  reversal 
of  the  normal  formulae  as  shown  by  distmct  cathodal  opening  con- 
tractions. 

Diagnosis.  Hemiplegia  from  acute  cerebral  affections  in  children 
can  be  distinguished  from  infantile  paralysis  by  the  disorders  of  in- 
telligence and  the  special  senses,  and  the  perseverance  of  the  normal 
electro-contractility. 

Paralysis  of  myelitis  occurs  in  older  persons,  and  is  associated  with 
disturbances  of  the  genito-urinary  organs  and  bedsores. 

Pseudo-muscular  hypertrophy,  with  paralysis,  begins  gradually, 
becoming  progressively  worse  with  increase  in  the  size  of  the  limbs. 

Progrnosis.     Depends  upon  the  treatment.    If  prompt  and  proper, 


DISEASES   OF   THE   SPINAL   CORD.  339 

recovery  may  be  said  to  be  the  rule.  Mild  cases  recover  within  a  few 
days,  others  as  many  weeks,  more  severe  cases  a  month  or  two.  If 
proper  treatment  be  not  pursued  for  several  months  or  years,  the 
question  of  final  recovery  can  be  determmed  by  testing  for  the 
"reactions  of  regeneration"  with  the  galvanic  current.  There  is  no 
danger  to  hfe. 

Treatment.  The  diagnosis  during  the  initial  fever  is  impossible, 
so  that  its  treatment  is  symptomatic.  On  the  appearance  of  the 
paralysis  complete  rest ;  hot  spinal  douche,  mild  galvanism,  and 
internally,  quinina,  belladonna  and  ergota. 

With  the  improvement  that  follows  the  above  measure,  use  inter- 
nally, tinctura  nucis  vomicce,  Hij-iij  t.  d.,  or  hypodermic  injections  of 
strychnincE  sulphas,  gr.  ^  to  y^  twice  a  week,  ^.ndi  faradism  to  the 
paralyzed  muscles. 


CHRONIC  PROGRESSIVE  BULBAR  PARALYSIS. 

Synonyms.     Glosso-labio-laryngeal  paralysis;  bulbar  paralysis. 

Definition.  A  progressive  muscular  paralysis  of  the  laryngeal 
muscles,  tongue,  soft  palate  and  lips. 

Causes.  Obscure.  Rare  before  the  fortieth  year.  Among  many 
others  are  named  cold,  rheumatism,  gout,  syphilis  and  injuries  about 
the  neck. 

Pathological  Anatomy.  "  Degenerative  atrophy  of  the  gray 
nuclei  in  the  floor  of  the  fourth  ventricle ;  with  atrophy  and  gray  dis- 
coloration of  the  nerve  roots  from  the  medulla,  especially  of  the  facial 
and  hypoglossal  nerves."  "Atrophy  and  disappearance  of  the  motor 
ganghon  cells  is  always  to  be  noted.     It  may  be  the  sole  lesion." 

"  The  nerves  going  to  the  muscles  exhibit  sclerosis  of  the  neuri- 
lemma, and  the  degenerative  atrophy  is  found  in  the  nerve  roots 
coming  from  the  bulb." 

Symptoms.  The  disease  begins  insidiously.  There  is  first 
noticed  some  difficulty  in  articulation,  from  want  of  precision  in 
movements  of  the  tongue,  which  increases  until  that  organ  is  com- 
pletely paralyzed.  The  paralysis  gradually  invades  the  soft  palate 
and  pharyngeal  muscles,  causing  difficulty  in  deglutition,  the  orbicu- 
laris oris,  preventing  closure  of  the  lips,  the  laryngeal  muscles  inter- 
fering with  articulation.  When  the  disease  is  fully  developed  the 
condition  of  the  patient  is  most  pitiable,  indeed;  articulation  is  im- 


340  PRACTICE   OF   MEDICINE. 

paired  or  impossible,  deglutition  interfered  with,  the  lips  remaining 
apart  allowing  the  saliva  to  dribble  from  the  mouth,  and  liquids  to 
return  through  the  nose  if  attempts  are  made  to  swallow  them.  As 
the  malady  advances  soon  the  pneumogastric  nucleus  becomes 
involved,  causing  loss  of  voice,  difficulty  of  respiration  and  cardiac 
irregularity.  The  general  health  gradually  suffers  from  insufficient 
nutrition  and  imperfect  respiration,  although  the  mind  is  clear  until 
the  end.     The  "  reactions  of  degeneration  "  are  present. 

Diagnosis.    It  can  hardly  be  confounded  with  any  other  malady. 

Prognosis.   Unfavorable.   The  duration  is  from  one  to  five  years. 

Treatment.  Entirely  symptomatic.  "  Galvanism  is  the  most 
promising  remedy.  Stabile  applications,  the  electrodes  on  the  mas- 
toid processes,  and,  in  the  opposite  direction,  galvanization  of  the 
sympathetic,  and  applications  to  the  lips,  tongue  and  fauces,  should 
be  persistently  used."     (Bartholow.) 


SPINAL   SCLEROSIS. 

S3monyni.     Duchenne's  disease. 

Definition.  A  myelitis ;  an  increase  in  the  connective  tissue  of 
the  spinal  cord,  with  atrophy  of  the  nerve  structure  proper. 

Varieties.  I.  Lateral  sclerosis  ;  II.  Cerebro-spitial  sclerosis ;  III. 
Posterior  sclerosis  or  locomotor  ataxia. 

Causes.  Generally  a  hereditary  neuropathic  diathesis  ;  syphilis  ; 
mineral  poisons  ;  shocks  or  injuries  to  the  cord  ;  exposure  to  cold  and 
wet ;  mostly  occurring  between  the  ages  of  thirty-five  and  fifty-five  ; 
males  more  hable  than  females.  It  is  said  that  railroad  enginemen 
and  firemen,  as  well  as  conductors  and  other  trainmen,  suffer  from  this 
and  other  spinal  diseases  by  reason  of  the  concussion. 

Pathological  Anatomy.  The  changes  in  the  cord  are  gradual 
in  their  development  and  follow  a  longitudinal  instead  of  a  transverse 
direction. 

The  form,  consistency  and  color  of  the  cord  are  altered,  it  being 
atrophied,  indurated  and  of  a  grayish  color. 

The  changes  are  hyperplasia  of  the  connective  tissue,  with  granular 
degeneration,  atrophy  and  disappearance  of  the  proper  nerve  ele- 
ments. The  nerve  roots  undergo  the  same  fibroid  change.  The  joints 
undergo  remarkable  atrophic  degeneration. 


DISEASES   OF   THE   SPINAL   CORD.  341 

LATERAL   SCLEROSIS. 

Synonyms.  Antero-lateral  sclerosis ;  spasmodic  tabes  dorsalis 
(Charcot) ;  spastic  spinal  paralysis  (Erb). 

Pathogeny.  The  site  of  the  lesion  is  the  lateral  white  columns, 
in  some  cases  extending  to  the  anterior  horn,  extending  the  whole 
length  of  the  cord.  The  changes  consist  in  an  interstitial  hyperplasia 
of  the  connective  tissue  and  an  atrophy  of  the  nerve  elements. 

Symptoms.  The  chief  symptom  is  paraplegia,  or  entire  loss  of 
motion  in  the  lower  extremities.  Preceding  the  paralysis  there  occur 
jerking  and  twitching,  with  cramps  atid  stiffness  of  the  muscles  of 
the  affected  parts.  As  the  disease  is  progressing  the  gait  is  of  a  pecu- 
liar character,  termed  by  Hammond  "the  waddle,"  the  patient  step- 
ping on  the  toes  and  showing  a  tendency  to  fall  forward.  There  is  a 
gradual  and  increasing  feeling  of  heaviness  and  weakness  in  the 
affected  limbs.  Sensation  is  unaffected.  Reflex  phenomena  are 
preserved,  at  times  greatly  exalted.  As  the  morbid  process  extends 
upward,  the  superior  extremities  suffer  in  the  same  manner  as  those 
of  the  lower. 

Electro- contractility  early  impaired,  and  gradually  declining  until 
abolished. 

CEREBRO-SPINAL   SCLEROSIS. 

Synonyms.  Multiple  sclerosis  of  the  brain  and  cord ;  cerebral 
sclerosis  ;  spinal  sclerosis  ;  disseminated  sclerosis  (Charcot). 

Pathog'eny.  The  disease  consists  of  the  development  of  patches 
of  grayish,  translucent,  tough  nodules,  varying  in  size  from  a  minute 
microscopical  object  up  to  the  size  of  a  walnut,  varying  in  number 
and  widely  distributed  in  the  white  matter  of  the  hemispheres,  ven- 
tricles, optic  thalamus,  corpus  striatum,  peduncles,  pons  and  cere- 
bellum, while  in  the  cord  they  are  found  in  both  the  white  and  gray 
matter  and  in  the  columns.  The  deposits  are  also  found  in  the  nerve 
roots  and  nerve  trunks.  The  nodules  are  composed  of  the  neuroglia 
much  altered  and  a  newly-formed  connective  tissue.  The  result  of 
the  nodules  is  pressure  upon  the  nerve  structure,  ending  in  its  degen- 
eration. 

Symptoms.  Charcot  divides  this  variety  of  sclerosis  into  three 
varieties,  depending  upon  the  site  of  the  marked  changes,  as  the 
brain,  the  cord  or  a  combination  of  the  two.  The  latter  variety  is 
the  more  common. 


342  PRACTICE   OF   MEDICINE. 

Rarely  the  malady  is  ushered  in  with  apoplectiform  symptoms,  but 
generally  the  onset  is  insidious,  with  pains  more  or  less  severe  in  the 
limbs  and  back,  which  are  attributed  by  the  patient  to  rheumatism. 
Also  a  feeling  of  formication,  itching  and  burning  in  the  limbs.  Loss 
of  coordination  of  the  hands  in  writing,  or  the  feet  in  walking,  fol- 
lowed after  a  time  by  paresis,  more  or  less  general,  with  contracture 
of  the  muscles.  Voluntary  movements  of  the  paretic  limbs  develop 
a  tremor — the  shaking  tremor — which  subsides  when  the  limbs  are  at 
rest.  It  is  these  motor  symptoms  that  have  given  rise  to  the  "wad- 
dle," or  "hop"  gait  when  walking.  There  are  also  present  ^<?«^- 
ache,  vertigo,  niejital  disturbances,  nausea,  dyspeptic  distresses,  dis- 
orders of  vision  and  hearing,  sexual  disturbances,  vesical  disorders, 
and  often  the  development  of  bedsores. 

The  disease  is  progressive,  the  symptoms  developing  as  the  various 
nerve  tracts  are  invaded. 

Duration.  Ranges  from  a  year  to  twenty  years,  an  average  being 
five  or  ten  years. 

PROGRESSIVE   LOCOMOTOR   ATAXIA. 

Synonyms.     Posterior  spinal  sclerosis  ;  tabes  dorsalis. 

Pathog'eny.  The  sclerosis  begins  and  may  be  confined  to  the 
posterior  columns  in  the  upper  lumbar  and  dorsal  regions.  Fre- 
quently it  extends  the  entire  length  of  the  cord  and  invades  the 
lateral  columns.  The  sclerotic  changes  also  invade  the  sciatic,  crural 
and  brachial  nerves. 

Symptonis.  Locomotor  ataxia  may  be  divided  into  three  pe- 
riods: I,  disturbances  of  sensation  ;  2,  loss  of  coordinating  power ;  3, 
paralysis. 

The  onset  of  the  disease  is  gradual  by  sharp,  darting,  electric-like 
pains  in  the  lower  limbs,  with  disorders  of  the  gastro-intestinal  and 
genito-urinary  tracts.  Associated  with  the  pains  is  a  loss  of  sensation 
in  the  feet,  the  patient  being  unable  to  distinguish  between  hard  and 
soft  substances  in  walking,  and,  if  the  upper  portion  of  the  spinal  cord 
be  affected,  is  unable  to  coordinate  the  muscles  of  the  fingers  suffi- 
ciently to  button  his  clothing.  A  sensation  of  formication  over  the 
surface,  especially  over  the  lower  limbs,  and  about  the  waist,  the 
knee  and  the  ankle. 

Loss  of  coordination,  the  subject  being  unable  to  walk  upon  a 
straight  line  with  his  eyes  closed,  and  with  difficulty  if  his  eyes  are 


DISEASES   OF   THE   SPINAL   CORD.  343 

opened.  Inability  to  preserve  the  erect  position  with  the  feet  close 
together,  and  as  the  malady  progresses  he  throws  his  feet  and  legs  in 
the  most  grotesque  manner.  Although  the  patient  is  unable  to  coor- 
dinate the  muscles,  their  power  is  not  lost,  for,  on  being  supported,  he 
can  kick  or  strike  with  his  usual  force. 

The  sight  is  early  impaired ;  either  double  vision  or  inability  to  dis- 
tinguish between  different  colors.  As  the  disease  progresses  the  sen- 
sation becomes  more  and  more  blunted  and  pain  is  slowly  felt,  in 
cases  it  being  several  minutes  until  the  sticking  of  a  pin  is  felt.  A 
characteristic  sign  of  the  disease  is  the  abolition  of  the  patellar  tendon- 
7-eflex  as  well  as  other  reflexes  in  the  lower  limbs.  Loss  of  the  sensa- 
tion of  temperature  also  occurs.  T  he  electro-contractility  is  decreased 
in  the  affected  limb.     General  emaciation  is  marked. 

Paralysis  finally  ends  the  suffering  of  the  patient.  There  is  gener- 
ally an  entire  absence  of  cerebral  phenomena. 

Diagnosis.  The  symptoms  of  these  three  varieties  of  sclerosis 
are  so  characteristic  that  with  care  an  error  in  the  diagnosis  seems 
impossible. 

Chronic  myelitis  is  characterized  by  paralysis,  and  the  course  of  the 
affections  are  otherwise  so  different  that  an  error  should  not  occur. 

Disease  of  the  cerebellum  presents  symptoms  of  disordered  coordi- 
nation, but  they  are  the  result  of  vertigo,  and  associated  with  head- 
ache, nausea  and  vomiting. 

Paraplegia  is  a  true  paralysis,  while  sclerosis  is  not.  Neuralgic 
pain  is  not  a  symptom  of  paraplegia. 

Paralysis  agitans  may  be  mistaken  for  disseminated  sclerosis.  Chief 
points  in  the  diagnosis  are  the  presence  in  paralysis  agitans  of  the  fine 
tremor  continually  without  shaking  of  the  head,  while  in  cerebro- 
spinal sclerosis  the  tremor  is  produced  only  on  movement  of  the 
muscle,  and  is  associated  with  shaking  of  the  head.  Paralysis  agitans, 
a  disease  of  middle  life,  sclerosis  under  forty  years.  Changes  in  the 
voice,  speech  and  vision  are  present  in  cerebro-spinal  sclerosis,  but 
absent  in  paralysis  agitans. 

Prognosis.  Unfavorable.  Few  if  any  recoveries  are  recorded  of 
antero-lateral  or  disseminated  sclerosis,  although  rarely  their  progress 
has  been  retarded  for  a  long  time.  There  are  some  claims  of  recov- 
eries of  locomotor  ataxia  in  the  early  stage,  but  that  a  cure  of  a  gen- 
uine case,  extending  to  the  second  stage,  is  ever  effected,  seems  very 
questionable. 


344  PRACTICE   OF   MEDICINE. 

Treatment.  In  the  management  of  the  various  scleroses,  rest,  as 
near  absolute  as  possible,  is  of  the  first  importance, — it  will  be  all  the 
more  effective  if  it  be  in  bed,  for  a  period  of  several  months. 

Following  the  suggestion  of  Erb,  use  may  be  made  of  cold  along 
the  spine,  in  the  shape  of  cold  sponging,  cold  spinal  pack  or  short 
application  of  the  cold  douche  to  the  spine.  T\\q  galvanic  continuous 
current  along  the  spinal  column  is  warmly  advocated,  \v\\k\.  faradisin 
to  the  wasting  muscles. 

Potassii  iodidum,  or  hydrargyri  chloridum  corrosivum,  in  full  doses, 
or  atirii  et  sodii  chloridum,  gr.  ^,  three  times  a  day,  often  remarkably 
retard  the  progress  of  the  affection.  The  best  results  are  obtained, 
however,  from  argenti  7iitras ,  gr.  X~/^>  or  oxidu?n,gr.  yi,  three  times 
a  day,  withholding  it  at  intervals  of  a  few  weeks,  to  prevent  discolor- 
ation of  the  skin  (argyria). 

Temporary  success,  at  least,  seems  to  have  followed,  in  some  cases 
of  locomotor  ataxia,  from  the  '' suspefision  treatment  as  recom- 
mended by  Charcot.  The  treatment  consists  of  the  suspension  of  the 
patient  during  a  period  varying  from  one  to  four  minutes,  by  means 
of  the  Sayre  apparatus  for  applying  the  plaster  jacket  in  spinal 
deformities. 

The  severe  and  sharp  pains  require  treatment,  at  first  giving  prefer- 
ence to  any  of  the  substitutes  of  opium,  but  finally  opiu7n  itself  will 
have  to  be  resorted  to. 

The  diet  should  be  of  a  nutritious,  easily-assimilated  character. 
Nutrition  can  also  be  promoted  by  the  use  of  oleum  mon'hu<z  and 
syrupus  calcii  lacto-phosphatis. 


PROGRESSIVE  MUSCULAR  ATROPHY. 

Synonym.     Wasting  palsy. 

Definition.  A  gradual,  progressive  wasting  and  atrophy  of  the 
voluntary  muscular  system,  resulting  from  trophic  changes  due  to  a 
central  nerve  lesion. 

Causes.  In  many  instances  the  disease  is  hereditary.  A  predis- 
posing cause  seems  to  exist  in  those  who  habitually  use  one  set  of 
muscles.  Exposure  to  cold  and  damp  ;  lead,  syphilis ;  injuries  to  the 
spinal  column. 

Patholo^cal  Anatomy.  Two  theories  as  to  the  origin  of  the 
pathological  changes  are  held  :  one  that  the  initial  lesion  is  in  the 


DISEASES   OF   THE   SPINAL  CORD.  345 

cord  (Charcot),  the  other  in  the  muscular  interstitial  connective  tissue 
(Friedreich). 

The  morbid  alterations  are  of  two  groups — spinal  and  muscular. 
,  The  spinal  changes  consist  in  the  atrophy  and  degeneration  of  the 
anterior  columns,  wasting  and  disappearance  of  the  muldpolar  gan- 
glion-cells of  the  anterior  horns,  and  hyperplasia  of  the  neuroglia, 
and  wasting,  atrophy  and  degeneration  of  the  anterior  nerve  roots. 

The  muscular  changes  consist  of  a  progressive  wasting  of  the  mus- 
cular tissue,  with  increase  of  the  interstitial  connective  tissue.  "The 
final  result  is,  that  the  muscle  is  converted  into  a  mere  fibrous  band 
with  numerous  fat-cells,  the  development  of  this  latter  material  taking 
place  outside  of  the  muscular  elements  and  in  the  newly-formed  con- 
nective tissue."     (Bartholow.) 

Symptoms,  The  invasion  is  gradual,  the  disease  having  been 
in  progress  some  weeks  or  months  before  the  patient  discovers  its 
existence. 

Wasting  begins  usually  in  the  hand,  the  first  dorsal  inter-osseus 
being  the  first  to  be  attacked,  then  the  muscles  of  the  thenar  and 
hypothenar  ejninence,  then  the  deltoid,  and  so  on  from  muscular  group 
to  group.  Often,  however,  the  extension  is  very  erratic  in  its  course, 
jumping  from  one  group  to  another  at  some  distance. 

In  the  immense  majority  of  cases  the  disease  is  permanently  limited 
to  one  or  a  few  groups  of  muscles  in  the  upper,  or  more  rarely  in  the 
lower  extremities.  The  only  muscles  not  yet  known  to  be  attacked  are 
those  of  mastication  and  those  that  move  the  eye-ball  (Roberts). 

Fibrillary  contractions  is  an  early  symptom,  continuing  more  or 
less  marked  so  long  as  any  muscular  fibres  remain.  It  consists  of 
wave-like  movements  of  the  muscles,  excited  automatically,  by 
draughts  of  air  or  percussion.  Coincident  with  the  wasting  is  loss 
of  power,  disorders  of  sensation^  coolness  of  the  surface,  2in6.  pallor 
of  the  surface. 

The  natural  roundness  and  contour  of  the  body  and  limbs  are 
changed,  the  bones  standing  out  in  unaccustomed  distinctness,  giving 
the  individual  the  appearance  of  a  skeleton  clothed  in  skin.  The 
hand  is  frequently  the  seat  of  a  very  singular  deformity — the  "  claw- 
shaped"  hand. 

The  electro- contractility  is  preserved  so  long  as  muscular  fibres 
remain. 

Diagnosis.  >When  wasting  palsy  is  fully  developed  its  diagnosis 
29 


346  PRACTICE   OF   MEDICINE. 

is  a  simple  matter.  In  its  early  stages  a  doubt  may  exist,  but  atten- 
tion to  the  history,  symptoms  and  progress  will  determine  the  ques- 
tion. 

ProgTiosis.  Very  unfavorable,  although  the  danger  of  life  is  often 
very  remote.  The  disease  may  be  arrested  and  remain  stationary  for 
years. 

Treatment.  Internal  medication  seems  to  have  no  effect  on  the 
malady,  although  if  mineral  poisoning  be  suspected  />o/assn  zodi'dum 
should  be  used,  and  if  syphilis  be  suspected  a  course  of  potassii  iodi- 
du)n  and  hydrargyruvi  should  be  administered. 

If  the  disease  is  the  result  of  overworking  any  set  of  muscles,  these 
must  be  allowed  a  rest. 

"  The  most  effective  remedy  in  wasting  palsy  is,  undoubtedly,  ^rt/- 
vatiism.  Numerous  observations  attest  its  value  when  applied  locally 
to  the  affected  muscles  "  (Roberts). 

I  have  seen  improvement  from  the  faradic  current  to  the  affected 
muscles,  the  strength  being  simply  sufficient  to  produce  contractions. 

Massage  is  a  valuable  adjuvant  to  the  electrical  treatment,  as  are 
hot  sponging  and  rubbiitg  along  the  spine. 

Prof.  Bartholow  "has  apparently  effected  great  improvement  in  a 
case,  confined  as  yet  to  the  left  upper  extremity,  by  the  injection  of 
glycerine  solution  into  the  wasting  muscles." 


CEREBRO-SPINAL  NEUROSES. 


CHOREA. 

Synonyms.     St.  Vitus's  dance  ;  insanity  of  the  muscles. 

Definitions.  A  functional  (?)  disorder  of  the  nervous  system : 
characterized  by  irregular  spasmodic  movements  of  groups  of  muscles, 
with  muscular  weakness,  more  or  less  approaching  paralysis  of  the 
affected  parts. 

Causes.  Essentially  a  disease  of  childhood  ;  hereditary  ;  reflex 
from  dentition,  worms,  masturbation  or  fright;  probably  the  result  of 
rheumatism  in  many  cases. 


CEREBRO-SPINAL  NEUROSES.  347 

Pathological  Anatomy.  As  yet  there  has  been  no  constant 
anatomical  lesion  discovered,  the  theory  of  emboli  having,  however, 
many  advocates. 

Symptoms.  The  onset  is  usually  gradual,  the  child  seemingly 
grimacing  or  jerking  the  arm  or  hand,  as  if  in  imitation,  followed 
by  decided,  irregular  jactations  of  the  muscles  of  the  face  (histrionic 
spasm),  of  the  eyelids  (blepharospasm),  eyeballs  (nystagmus),  and 
the  shoulder,  arm  and  hand,  finally  extending  to  the  lower  extremi- 
ties, interfering  with  motility;  in  severe  cases,  inability  of  self-feeding 
or  of  holding  anything  in  the  hands.  The  speech  is  often  unintelligible, 
the  tongue  constantly  moving  in  an  irregular  manner. 

The  heart's  action  is  tumultuous  and  irregular,  associated  with  a 
soft,  blowing,  systolic  murmur,  most  distinct  at  the  base.  The  mus- 
cles are  usually  quiet  during  sleep,  although  this  is  not  always  the 
case.  The  mind  is  somewhat  blunted,  the  temper  irritable,  the 
memory  impaired.  If  the  irregular  muscular  movements  are  con- 
fined to  one  side  of  the  body  it  is  termed  hetni-chorea. 

Diagnosis.  Chorea  was  confounded  with  epilepsy  until  the  points 
of  distinction  were  pointed  out  by  Sydenham. 

Paralysis  agitans  has  general  muscular  tremor,  beginning  in  one 
limb,  gradually  progressing,  uninfluenced  by  treatment ;  a  disease  of 
the  elderly. 

Post-hemiplegic  chorea  is  the  choreic  movement  of  a  paralyzed  limb. 

Prognosis.  The  vast  majority  of  cases  recover,  but  relapses  are 
very  frequent. 

Treatment.  Remove  the  cause,  if  possible.  Easily  assimilated 
diet.  Many  cases  improve  rapidly  by  confinement  to  bed  in  a  dark- 
ened room.  If  the  muscular  movements  interfere  with  sleep,  mor- 
phina  or  chloral  are  indicated.     Regulate  the  secretions. 

Arsenicwn  is  the  most  reliable  remedy  yet  introduced  for  the  treat- 
ment of  chorea.  It  should  be  pushed  to  its  first  physiological  effects, 
then  gradually  reducing  the  dose  until  all  symptoms  disappear.  The 
form  of  the  remedy  best  adapted  for  administration  in  this  disease  is 
liquor  potassii  arsenitis,  gtt.  v,  increased  to  gtt.  x,  or  even  gtt.  xv, 
three  times  a  day.  Extractwn  ciinicifugcB  fiuidu7n,  Ti^xx-3j,  t.  d., 
is  serviceable,  especially  in  cases  following  a  rheumatic  attack. 
Cases  resisting  the  arsenicum  treatment  may  succumb  to  hyos- 
cyamine,  gr.  ^^—j-^.  three  times  daily.  A  patient  of  mine,  aged 
1 6   years,  that  resisted    all  the  remedies  mentioned,  was  promptly 


348  PRACTICE   OF    MEDICINE, 

cured  by  antipyrine,  gr.  x,  four  times  daily.  The  same  case  in  a  former 
attack  was  arrested  by  ))io7-phincE  sulphas,  gr.  %,  four  times  daily, 
but  this  latter  remedy  failed  in  the  attack  controlled  by  the  anti- 
pyrine.  If  anaemia  be  present,  combine  or  alternate  arsenicum  with 
f err  urn. 

EPILEPSY. 

Definition.  A  chronic  disease,  of  which  the  characteristic  symp- 
toms are  a  sudden  loss  of  consciousness,  attended  with  more  or  less 
general  convulsions. 

Causes.  Heredity  ;  rarely,  worry,  anxiety,  depression  or  fright. 
Pressure  from  a  tumor  at  the  periphery,  or  thickening  of  the  mem- 
branes of  the  brain,  causing  pressure  ;  dyspepsia  (?) ;  syphilis  ;  uterine 
diseases. 

Pathological  Anatomy.  There  are  no  constant  anatomical 
lesions,  as  yet,  associated  with  epilepsy. 

Varieties.  I.  Epilepsia  gravior,  le  grand  mal ;  II.  Epilepsia 
mitior,  le  petit  mal. 

Symptoms.  Le  grand  mal  is  preceded  by  a  more  or  less  pro- 
nounced and  curious  sensation,  the  so-called  atcra  epHeptica. 

The  attack  proper  is  siiddeti,  the  subject  suddenly  fallijig,  with  a 
peculiar  cry,  loss  of  consciousness,  and  pallor  of  the  face,  the  body 
assuming  a  position  of  tetanic  rigidity,  succeeded  after  a  few  mo- 
ments by  more  or  less  pronounced  clonic  convulsions,  followed  by  a 
coma  of  several  hours'  duration.  The  subject  awakens  with  a  con- 
fused or  sheepish  expression,  with  no  knowledge  of  what  has  occurred, 
unless  he  has  injured  himself  during  the  attack,  either  by  the  fall,  or, 
what  is  very  common,  has  bitten  his  tongue  during  the  convulsions. 

Le  petit  mal  is  manifested  either  by  attacks  of  vertigo,  the  conscious- 
ness being  preserved,  or  by  2i  passing  absent-mindedness,  either  form 
being  associated  with  slight  convulsive  phenomena,  followed  by  coma 
of  short  duration.  * 

The  mental  functions  are  not,  as  a  rule,  injured  by  attacks  of  epi- 
lepsy, unless  they  recur  very  frequently.  Indeed,  when  at  wide 
intervals,  the  subject  seems  relieved  by  them,  "  the  sudden,  excessive 
and  rapid  discharge  of  gray  matter  of  some  part  of  the  brain  on  the 
muscles,"  the  so-called  "electrical  storm,"  having  cleared  the  cere- 
bral atmosphere. 

Diagnosis.     Urcemic  convulsions   closely  resemble   an  epileptic 


CEREBRO-SPINAL   NEUROSES.  349 

attack ;  but  the  dropsy  or  general  oedema  and  albuminous  urine  of 
the  former  should  guard  against  error. 

Feigned  epilepsy  often  misleads  the  most  practical  expert. 

Prog'nosis.  The  vast  majority  of  cases  will  not  recover  under 
treatment,  but  have  the  frequency  and  severity  of  the  attacks  greatly 
ameliorated,  but  sooner  or  later  returning  with  their  former  severity. 
Cases  the  result  of  the  various  reilex  causes  usually  recover  when  the 
cause  is  removed. 

Treatment.  To  avert  an  impending  attack,  inhalations  of  amyl 
nitris,  gtt.  iij-v,  a  few  whiffs  of  chloroforinum,  or  the  hypodermic 
injection  of  morphma. 

To  prevent  the  return  of  attacks,  remove  the  cause  if  possible ; 
attention  to  the  secretions,  and  the  internal  administration  of  potassii 
bro?mdum  in  doses  sufficient  to  abolish  the  faucial  reflex  and  produce 
the  symptoms  of  bromism,  has  great  power  in  diminishing  the 
severity  and  frequency  of  the  attacks ;  better  results  are  sometimes 
obtained  by  the  combination  of  the  various  bromides.  Cases  in 
which  the  bromides  are  not  serviceable  are  sometimes  benefited  by 
argenti  nitras,  belladonna,  or  cannabis  indica.  Weak  and  anaemic 
subjects  usually  do  better  with  strychnina  in  full  doses  than  with 
potassii  bromidum.  If  a  history  of  syphilis  can  be  obtained,  the 
combination  of  potassii  iodiduni  and  potassii  bro7nidum  will  effect  a 
cure. 

Whichever  of  the  above  remedies  are  beneficial  in  any  particular 
case,  the  permanency  of  the  relief  can  only  be  maintained  by  the 
continuation  of  the  drug  for  at  least  two  years  after  the  last  attack. 

Gowers  highly  recommends  the  following  in  cases  complicated  with 
cardiac  dilatation  : — 

R  .     Potassii  bromid., gr.  xx 

Tinct.  digital., Tli^x.  M. 

SiG. — Three  times  a  day. 

Another  good  combination  is  the  following : — 

Ij^.     Potassii  bromid., .  gr.  xv 

Sodii  bromid.,     ...  .  sr.  xv 

JLiq,  potassn  arsenit., rt\^ij 

Ext.  conii  fid., n\^iij 

Aq.  cinnamomi, ^j 

Inf.  gentian  comp., ad  ....  ^bs. 

SiG. — Two  hours  after  meals. 


350  PRACTICE   OF   MEDICINE. 

Brown-Sequard's  mixture  for  epilepsy  is  as  follows : — 

R.     Potassii  iodidi, 8  parts. 

Potassii  bromidi, 8     " 

Ammonii  bromidi, 4     " 

Potassii  bicarb., 5     " 

Inf.  columbo, 360     " 

SiG. — One    teaspoonful   before    meals  and    three  dessertspoonfuls    on 
going  to  bed. 

Prof.  Da  Costa  has  used  with  success  a  bromide  of  nickel  m  cases 
that  have  withstood  the  other  combinations  of  the  bromides. 


HYSTERIA. 

Definition.  A  functional  disorder  of  the  nervous  system,  of  the 
nature  of  which  it  is  impossible  to  speak  definitely  ;  characterized  by 
disturbances  of  the  will,  reason,  imagination  and  the  emotions,  as 
well  as  motor  and  sensory  disturbances. 

Causes.  A  morbid  condition  confined  almost  exclusively  to 
women.  Young  girls,  old  maids,  widows  and  childless  married 
women  are  the  most  frequent  subjects  of  this  disorder.  The  parox- 
ysms frequently  develop  during  the  menstrual  epoch.  The  meno- 
pause is  another  frequent  period  for  its  manifestation.  A  peculiar 
condition  of  the  nervous  system,  either  inherited  or  acquired,  is 
responsible  for  the  phenomena  of  hysteria,  the  peculiar  manifesta- 
tions being  excited  by  disturbances  of  either  the  sexual,  digestive, 
circulatory  or  nervous  systems. 

Hypochondriasis,  a  peculiar  mental  condition,  characterized  by 
inordinate  attention  on  the  part  of  the  patient  to  some  real  or  sup- 
posed bodily  ailment  or  sensation,  as  seen  in  males,  is  a  condition 
much  like  the  hysteria  of  the  female. 

Pathogeny.  Structural  alterations  have  thus  far  not  been 
detected  in  cases  of  hysteria ;  it  is  thus  a  functional  disturbance  of 
the  nervous  system.  It  should,  however,  be  borne  in  mind  that 
hysterical  manifestations  frequently  develop  during  the  prevalence  of 
organic  diseases. 

Symptoms.  These  will  be  considered  under  the  headings  of 
the  hysterical  paroxysms  and  the  hysterical  state. 

The  Hysterical  Paroxysm  or  Fit  occurs  nearly  always  in  the  pres- 
ence of   others,  and  develops   gradually  with  sighing,  meaningless 


CEREBRO-SPINAL   NEUROSES.  351 

laughter,  causeless  moaning,  nonsensical  talking  and  gesticulations, 
or  a  condition  of  fidgets,  followed  with  a  sensation  of  choking, 
dyspncea  and  a  ball  in  the  throat,  the  globus  hystericus.  These  and 
similar  symptoms  precede  the  fit,  during  which  the  unconsciousness  is 
only  apparent,  the  patient  being  aware  of  what  is  transpiring  about 
her.  During  the  paroxysm  the  patients  may  struggle  violently,  throw- 
ing themselves  about,  their  thumbs  turned  in  and  their  hands 
clenched.  Again,  spasmodic  movements  occur,  varying  from  slight 
twitching  in  the  limbs  to  powerful  general  convulsive  movements,  to 
almost  tetanic  spasms.  ' 

The  paroxysm  ends  by  sighing,  laughing,  crying  and  yawning, 
and  a  sensation  of  exhaustion.  During  the  attack  it  will  be  noted 
that  the  surface  and  face  are  normal,  showing  absence  of  respiratory 
embarrassment  the  breathing  varying  from  very  quiet  to  spluttering 
and  gurgling  sounds,  the  pupils  not  dilated,  the  pulse  normal,  the 
temperature  normal,  and  absence  of  foaming  at  the  mouth  and 
wounding  of  the  tongue. 

The  Hysterical  State  is  shown  by  disturbances  of  the  mental,  sen- 
sory-motor functions  respectively.  It  may  be  a  permanent  condition 
or  occur  at  intervals  with  greater  or  less  severity. 

Mental  disturbances.  The  patients  are  emotional,  erratic,  excit- 
able, impatient  and  self-important,  showing  marked  defects  of  will 
and  mental  power. 

Sensory  disturbances.  This  is  either  a  condition  of  exaggerated 
sensibility  or  hypersesthesia,  as  shown  by  the  marked  effects  from  the 
slightest  irritation  and  the  cutaneous  tenderness  along  the  spine,  or  a 
condition  of  ansesthesia  as  shown  by  the  apparent  absence  or  recog- 
nition of  pain  after  severe  irritation,  or  a  perverted  sensibility  as 
shown  by  the  feeling  of  tingling,  numbness  and  formication.  Sensi- 
bility to  heat  or  cold  are  often  absent.  There  is  great  perversion  of 
the  special  senses  in  many  of  the  cases. 

Charcot,  referring  to  the  ovarian  hyperaesthesia  of  hysteria,  says  : 
"  It  is  indicated  by  pain  in  the  lower  part  of  the  abdomen,  usually 
felt  on  one  side,  especially  the  left,  but  sometimes  on  both,  and  occu- 
pying the  extreme  limits  of  the  hypogastric  region.  It  may  be 
extremely  acute,  the  patient  not  tolerating  the  slightest  touch  ;  but  in 
other  cases  pressure  is  necessary  to  bring  it  out.  The  ovary  may  be 
felt  to  be  tumefied  and  enlarged.  When  the  condition  is  unilateral, 
it  may  be  accompanied  with  hemianaesthesia,  paresis,  or  contracture 


352  PRACTICE   OF   MEDICINE. 

on-  the  same  side  as  the  ovarialgia  ;  if  it  is  bilateral,  these  phenomena 
also  become  bilateral.  Pressure  upon  the  ovary  brings  out  certain 
sensations  which  constitute  the  aura  hysterica,  but  firm  and  systematic 
compression  has  frequently  a  decisive  effect  upon  the  hysterical  con- 
vulsive attack,  the  intensity  of  which  it  can  diminish,  and  even  the 
cessation  of  which  it  may  sometimes  determine,  though  it  has  no  effect 
upon  the  permanent  symptoms  of  hysteria." 

Motor  disturbances.  These  phenomena  embrace  every  variety  of 
motor  disturbance,  from  exaggerated  excitable  movements  to  defect- 
ive or  complete  loss  of  power.  With  the  paralysis  that  may  occur, 
neither  nutrition  nor  sensation  are  impaired.  Hysterical  paralysis  is 
liable  to  frequent  and  sudden  changes,  the  loss  of  power  often  disap- 
pearing suddenly.  Aphonia,  from  paralysis  of  the  laryngeal  muscles, 
is  a  frequent  form  of  paresis.  Some  hysterical  patients  refuse  to  even 
make  an  attempt  at  speech. 

"A  curious  enlargement  of  the  abdomen  is  observed  sometimes, 
constituting  the  so-called  phaiitom  tumor.  This  region  presents  a 
symmetrical  prominence  in  front,  often  of  large  size,  with  a  constric- 
tion below  the  margin  of  the  thorax  and  above  the  pubes.  The 
enlargement  is  quite  smooth  and  uniform,  soft,  very  mobile  as  a 
whole  from  side  to  side,  resonant  but  variable  on  percussion,  and  not 
painful.  Vaginal  examination  gives  negative  results,  and  under 
chloroform  the  prominence  immediately  subsides,  returning  again  as 
the  patient  regains  consciousness." 

Among  the  numerous  other  symptoms  that  may  develop  in  a 
hysterical  patient  are  disturbances  of  digestion,  the  circulation,  the 
respiration,  disorders  of  micturition  and  menstrical  disorders. 

Among  other  phenomena  that  belong  to  the  Hysterical  state  are 
to  be  mentioned  Hystero-epHepsy,  a  condition  of  hysteria  to  which  is 
superadded  the  convulsion,  epileptic  in  form  ;  Catalepsy,  a  condition 
in  which  the  will  seems  to  be  cut  off  from  certain  muscles,  and  in 
whatever  position  the  affected  member  is  placed,  it  will  so  remain  for 
an  indefinite  time.  There  may  or  may  not  be  unconsciousness  and 
loss  of  sensation  ;  Trance,  the  individual  lying  as  if  dead,  circulation 
and  respiration  having  alrnost  ceased  ;  Ecstacy,  a  condition  in  which 
the  individual  pretends  to  see  visions  and  acts  in  the  most  ridiculous 
manner. 

Diagnosis.  The  hysterical  state  is  so  general  in  its  manifestations 
that  it  is  to  be  borne  in  mind  in  diagnosing  all  ailments  occurring  in 


CEREBRO-SPINAL   NEUROSES.  353 

woman.  The  diagnosis  is  attended  with  great  difficulty,  however,  and 
requires  the  display  of  all  the  skill  of  the  clinician  to  prevent  error. 

Prognosis.  Death  from  either  a  hysterical  fit  or  the  hysterical 
state  is  the  rarest  of  events,  if  it  ever  occur.  The  ultimate  recovery 
of  a  hysterical  patient  is  of  frequent  occurrence.  Marriage  has  cured 
many  cases,  although  it  can  hardly  be  advised  by  the  physician. 

Treatment.  For  the  hysterical  fit  little  need  be  done,  as  a  rule, 
unless  the  paroxysm  is  violent  or  prolonged,  in  which  case  ammonii 
valerianate,  Hoffmaii  s  anodyne  or  spiritiis  ammonicB  aromaticus  may 
be  administered.  Charcot  recommends  the  making  of  firm  pressure 
over  the  ovarian  region  to  check  hysterical  fits  that  are  of  a  severe 
character. 

The  management  of  a  confirmed  case  of  hysteria  will  tax  the  skill 
of  the  most  astute  physician.  It  is  in  connection  with  hysteria  that 
the  peculiar  phenomena  supposed  to  arise  from  applying  different 
metals  to  the  surface  of  the  body  have  been  noticed. 

Moral  and  hygienic  measures  are  of  the  first  importance  in  the 
management  of  an  hysterical  patient.  The  treatment  by  isolation  of 
hysterical  patients  is  strongly  urged  by  many  specialists.  Dr.  S.  Weir 
Mitchell  has  devised  a  plan  for  bedfast  hysterical  patients,  of  massage, 
faradization  and  forced  feeding,  which  is  successful  in  a  fair  number 
of  cases. 

There  is  no  fixed  therapeutical  treatment  for  hysteria,  the  various 
symptoms  calling  for  interference  as  they  arise.  It  is  well,  however, 
to  avoid  the  use  of  stimulants,  opiates  and  chloral. 


NEURASTHENIA. 

Synonyms,  Spinal  irritation  ;  nervous  prostration  ;  nervous  ex- 
haustion. 

Definition.  A  debility  of  the  nervous  system,  causing  an  inability 
or  lessened  desire  to  perform  or  attend  to  the  various  duties  or  occu- 
pations of  the  individual. 

Prof.  Bartholow  describes  it  as  consisting  "  essentially  in  an  exag- 
gerated susceptibility  to  bodily  impressions  and  false  reasoning 
thereon." 

Causes.  It  may  result  from  various  chronic  diseases  ;  mental 
worry  or  emotion  ;  overwork,  as  "whenever  the  expenditure  of  nerve- 
force  is  greater  than  the  daily  income,  physical  bankruptcy  sooner 


354  PRACTICE   OF  MEDICINE. 

or  later  results"  (Jackson).  Neurotic  temperament;  sexual  excesses; 
alcohol ;  tobacco. 

Symptoms.  Nervous  debility  may  affect  any  organ  of  the  body. 
It  is  a  condition  of  nerve-tire  or  exhaustion,  and  hence  the  nervous 
energy  necessary  for  functional  activity  of  any  particular  organ  is 
wanting,  a  fair  example  being  seen  in  cases  of  nervous  dyspepsia. 

One  of  the  earliest  manifestations  of  nervous  exhaustion  is  an  irri- 
tability or  weakness  of  the  mental  faculties,  as  shown  by  inability  to 
concentrate  the  thoughts,  and  efforts  to  do  so  causing  headache,  ver- 
tigo, restlessness,  fear,  a  feeling  of  weariness  and  depression,  together 
with  the  army  of  symptoms  attendant  on  nervousness. 

There  may  be  ocular  disturbances,  cardiac  palpitation,  coldness 
of  the  hands  and  feet,  chilliness  followed  by  flashes  of  heat,  followed 
in  turn  by  slight  sweating.  Patients  are  troubled  with  insomnia,  or 
fatiguing  sleep  accompanied  with  unpleasant  dreams 

In  the  male  there  are  genito-urinary  disorders  with  pains  in  the 
back  giving  the  dread  of  impotence.  In  females,  painful  menstrua- 
tion, ovarian  irritation  and  irritable  uterus. 

Diagnosis.  It  is  of  importance  to  determine  between  a  true  ner- 
vous exhaustion,  and  nervous  debility  the  result  of  organic  disease. 
A  study  of  the  history  of  the  case,  together  with  the  symptoms,  should 
prevent  error. 

ProgTiosis.  Unless  there  be  a  tendency  to  mental  disorders  the 
prognosis  is  good. 

Treatment.  Attention  to  the  secretions,  diet  and  surroundings. 
Rest  and  diversion  of  mind  is  essential  to  success.  Travel,  short  of 
fatigue,  pleasant  companionship,  and  relief  from  responsibility. 
Bathing,  massage  and  galvanism  are  important  aids  to  the  manage- 
ment of  cases. 

Among  the  internal  remedies  that  are  of  benefit  may  be  mentioned, 
arsenicutn,  strych?tina,  ferrum,  zinci  valerianate,  phosphorus,  ex- 
tractum  cocce  Jluidum,  vinum  coccb  and  syrupus  hypophosphitis  comp. 

EXOPHTHALMIC  GOITRE. 

Synonyms.     Graves'  disease  ;  Basedow's  disease. 

Definition.  A  disease  of  the  nervous  system ;  characterized  by 
protrusion  of  the  eyeballs,  enlargement  of  the  thyroid  gland,  dilata- 
tion of  the  arteries  and  palpitation  of  the  heart. 


CEREBRO-SPINAL   NEUROSES.  355 

Causes.  An  undemonstrative  condition  of  the  nervous  system, 
either  inherited  or  acquired,  is  the  predisposing  cause  of  Graves' 
disease.  Among  the  exciting  causes  are,  anaemia,  shock,  fright, 
chagrin,  worry  and  reverses  of  fortune. 

It  is  more  common  in  women  than  in  men. 

Pathological  Anatoray.  "  Some  structural  alterations  have 
been  found,  in  a  majority  of  cases,  in  the  sympathetic  ganglia,  and 
especially  in  the  inferior  ganglia."  (Bartholow.)  The  veins  and 
arteries  of  the  thyroid  gland  are  dila.ted,  the  result  of  a  vasomoter 
paralysis.  The  enlargement  of  the  gland  is  the  result  of  the  dilated 
vessels,  a  serous  infiltration  of  its  tissues,  followed,  if  long  continued, 
by  hypertrophy.  A  considerable  mcrease  of  fat  behind  the  eyeballs 
has  been  observed.  In  the  majority  of  cases  more  or  less  anaemia 
exists. 

Symptoms.  The  development  of  the  quarternary  of  symptoms 
may  occur  suddenly,  the  result  of  some  great  shock  to  the  nervous 
system,  but  in  the  majority  of  instances  the  symptoms  develop  slowly 
and  insidiously,  with  cardiac  palpitation,  with  paroxysms  of  more 
marked  acceleration,  the  pulse  rate  varying  from  90  to  120,  150  and 
rarely  as  high  as  200  beats  per  minute  ;  soon  pulsations  of  the  vessels 
of  the  neck  and  thyroid  gland  may  be  felt  and  seen.  The  enlarge- 
ment of  the  thyroid  gland — the  goitre — appears  gradually  after  the 
development  of  the  circulatory  disturbances,  although  rarely  it  may 
be  the  first  symptom  observed.  The  goitre  is  elastic,  rather  soft, 
and  has, a  Mrz7/ similar  to  an  aneurism.  The  degree  of  enlargement 
varies  in  different  cases,  and  in  none  ever  attains  a  very  great  size. 
Following  the  development  of  the  goitre  occurs  the  protrusion  of  the 
eyeball — the  exophthalmus — which  may  be  confined  to  one  eye,  but 
usually  occurs  in  both.  Prominence  of  the  eyeball  may  be  the  first 
symptom  observed,  but  usually  it  does  not  develop  until  after  the 
appearance  of  the  goitre.  The  degree  of  protrusion  varies  from  a 
slight  staring  expression  to  a  point  so  great  that  the  eyelids  cannot 
cover  the  balls.  Associated  with  the  protrusion  of  the  eyeballs  is 
incoordination  in  the  movements  of  the  eyelids  and  the  eyeball,  the 
diagnostic  rule  of  Graefe,  so  that  when  the  eyes  are  quickly  cast  down 
the  eyelids  do  not  follow  them,  the  sclerotic  being  visible  below  the 
upper  lid.  Vision  is  unimpaired.  Conjunctivitis  may  arise,  the  result 
of  the  imperfect  protection  of  the  protruding  ball  by  the  eyelids. 

Associated   with  the  pathognomonic   symptoms   are  nervousness. 


356  PRACTICE   OF   MEDICINE. 

irritability  of  temper,  headache,  insomnia,  vertigo,  fits  of  despondency, 
aphonia  and  cough  the  result  of  pressure  of  the  goitre,  disorders  of 
digestion,  increase  of  temperature,  anaemia  and  loss  of  flesh. 

Diagnosis.  The  fully  developed  disease  presents  no  difficulties 
in  dia-^-nosis,  but  during  its  incipiency,  before  the  characteristic  symp- 
toms have  appeared,  the  disease  may  be  confounded  with  such  con- 
ditions as  cardiac  disease,  neurasthenia,  lithaemia,  malaria,  or  incipient 
phthisis. 

Prognosis.  Recovery  occurs  in  a  fair  numbers  of  cases,  but  is 
slow  and  tedious.  The  disorders  of  the  circulation  lead  to  dilated 
heart  in  many  cases,  and  ultimately  death  occurs  from  this  cause. 
Relapses  are  frequent. 

Treatment.  One  of  the  first  injunctions  to  be  placed  on  a  case 
of  exophthalmic  goitre  is  rest,  both  physical  and  mental,  as  well  as 
freedom  from  worry  or  emotional  excitement ;  little  progress  will  be 
made  if  this  point  be  neglected.  The  general  nervousness,  restless- 
ness and  insomnia  will  often  call  for  special  treatment,  when  use  may 
be  made  of  chloral,  poiassii  bromidum  or  siilphonal ;  it  is  better,  how- 
ever, not  to  use  this  class  of  drugs  in  a  routine  manner,  but  for  the 
special  indications. 

The  chief  indication,  next  to  rest,  is  the  condition  of  the  circulation. 
To  control  this  two  remedies  are  of  inestimable  value,  they  are  digi- 
talis and  sirophanthus.  The  results  I  have  seen  from  tinctura  stro- 
pha7ithus,  ■n\^v  from  three  to  six  times  daily,  have  been  most  satisfac- 
tory. Dr.  Bartholow  "  has  had  good  effects  from  quinina,  belladonna 
and  ergotin,  in  combination." 

The  associated  anaemia  is  to  be  treated  by  ferrum,  arsenicum  and 
an  easily  digestible  and  nutritious  diet.  Galvanism  to  the  cervical 
sympathetic  and  pneumogastric  is  an  important  adjuvant  to  the 
medicinal  treatment. 


DISEASES   OF  THE  NERVES.  357 


DISEASES   OF  THE   NERVES. 


NEURITIS. 

Definition.  An  inflammation  of  the  nerve  trunks ;  character- 
ized by  pain  and  paresis  of  the  parts  supplied  by  the  affected  nerve 
trunk. 

Causes.     Wounds  and  injuries  ;  cold  and  damp. 

Pathological  Anatomy.  Hyperaemia,  followed  by  exudation 
into  the  nerve,  "  which  becomes  softened  and  ultimately  breaks  down 
into  a  diffluent  mass."  Migration  of  white  corpuscles  takes  place  into 
the  neurilemma.  Recovery  may  occur  before  destruction  of  the 
nerve  elements  is  produced,  absorption  of  the  exudation  occurring. 
"  It  is  important  to  note  that  when  inflammation  occurs  in  a  nerve  it 
may  extend  from  the  point  first  diseased  upward  {neuritis  ascendens), 
or  downward  {neuritis  descendens).'' 

Symptoms.  The  onset  may  be  accompanied  with  febrile  reac- 
tion. The  most  decided  symptom  is  pain  along  the  course  of  the 
nerve  trunk  and  its  peripheral  distribution,  of  a  burning,  tingling, 
tearing,  intense  character,  increased  by  pressure  or  motion.  If  the 
affected  nerve  be  a  mixed  one — sensory  and  motor— spasmodic  con- 
tractions and  muscular  cramps  occur,  followed  by  impaired  motion, 
terminating  in  paresis  of  the  muscles  innervated  by  the  affected 
trunk. 

If  the  inflammation  proceed  to  destruction  of  the  nerve  trunk,  wast- 
ing and  degeneration  of  the  muscular  tissue  ensues.  Various  trophic 
changes  also  occur,  such  as  cutaneous  eruptions  and  clubbing  of  the 
nails.     The  electro-contractility  is  impaired  or  lost. 

Diagnosis.  Myalgia  or  muscular  pain  is  not  associated  with 
paralysis,  nor  does  the  pain  follow  the  course  of  a  nerve  trunk. 

Prognosis.     Generally  favorable,  with  proper  treatment. 

Treatment.  Repeated  blistering  along  the  course  of  the  nerve, 
with  full  doses  of  potassii  iodidum  are  usually  successful.  As  the 
more  acute  symptoms  subside  the  use  of  galvanism  or  a  feeble,  slowly 
interrupted /"ar^^^zr  current  restores  the  interrupted  function. 

For  the  pain  and  muscular  contractions,  hypodermic  injections  of 
morphina. 


35S  PRACTICE   OF   MEDICINE. 

NEUR.\LGIA. 

Definition.  A  disease  of  the  nervous  system,  manifesting  itself 
by  sudden  pain  of  a  sharp  and  darting  character,  mostly  unilateral, 
following  the  course  of  the  sensory  nerves. 

Varieties.  I.  Neuralgia  of  the  fifth  nerve ;  II.  Cervico-occipital 
neuralgia;  III.  Cervico-brachial  neuralgia ;  IV.  Dorso  intercostal 
neuralcria  :  \.  lADiibo-abdonitial  Jieitral^a  ;  VI.  Sciatica. 

Causes.  Heredity;  anaemia;  malaria;  syphilis;  metallic  poi- 
sons ;  anxiety  ;  mental  exertion  ;  exposure  to  cold  and  damp  ;  injuries 
of  a  nerve  trunk. 

Pathological  Anatomy.  The  old  axiom  of  neuralgia  being 
"the  cry  of  the  nerves  for  pure  blood"  is  perhaps  only  part  of  the 
truth.  The  changes  in  the  nerve  trunks  or  centres  have  not  as  yet 
been  determined.  A  fair  number  of  cases  present  the  changes  of 
neuritis. 

NEURALGIA   OF   THE   FIFTH    NERVE. 

Synonyms.     Tic-douloureux  ;  Fothergill's  disease. 

Symptoms.  Paroxysmal  pain,  of  a  sharp,  darting,  stabbing 
character,  most  common  at  points  along  the  course  of  the  supra-  and 
infra-orbital  branches  of  the  fifth  nerve  of  the  left  side,  attended  with 
increased  lachrymation.  When  of  any  duration  nutritive  changes  are 
observed  in  the  nervous  distribution,  to  wit:  osdema  along  the  course 
of  the  nerve,  gray  eyebrows  and  C07ivulsive  twitches  of  the  muscles, 
termed  "  tic-douloureux,''  tenderness  at  the  infra-  and  supra-orbital 
foramina,  as  well  as  along  the  course  of  the  nerve  distribution. 

CERVICO-OCCIPITAL  NEURALGIA. 
Symptoms.  Paroxysmal  pain,  of  a  sharp  and  lancinating,  or 
deep,  heavy,  tensive  character,  along  the  course  of  the  occipital  nerve 
upon  one  or  both  sides,  extending  from  the  vertex  and  on  the  neck 
as  far  down  as  the  clavicle,  and  upward  and  forward  to  the  cheek. 
May  be  associated  with  hyperesthesia  of  the  skin,  and  with  cramps  in 
the  cervical  muscles,  and  with  attacks  of  Jicrpcs.  A  sensation  of 
cracking  at  the  nape  of  the  neck  is  an  annoying  symptom  in  many 
cases. 

CERVICO-BKACHIAL   NEURALGIA. 

Symptoms.  Paroxysmal  pain,  of  a  severe,  boring,  burning  or 
tensive  character,  with  sensations  of  numbness  and  weakness  of  the 


DISEASES   OF  THE   NERVES.  359 

arm,  hand,  shoulder,  scapula  and  mamma,  with  tenderness  along  the 
cervical  plexus.  (Edema  of  the  arm  and  other  parts  along  the  dis- 
tribution of  the  cervical  plexus  occur  if  the  neuralgia  be  of  long  dura- 
tion, the  result  of  nutritive  changes,  the  hmb  at  times  becoming  pale, 
the  skin  glossy,  dry  and  harsh. 

DORSO-INTERCOSTAL   NEURALGIA. 

Symptoms.  Paroxysjnal  pain  of  a  sharp  and  lancinating  char- 
acter, along  the  fifth  and  sixth  intercostal  spaces,  often  associated 
with  the  development  of  herpes,  the  so-called  herpes  zoster,  or 
"  shingles." 

Tendertiess  at  the  points  where  the  nerves  emerge  from  the  inter- 
vertebral foramina  at  the  sides  of  the  chest  and  at  points  in  front. 

LUMBO- ABDOMINAL   NEURALGIA. 

SymptomiS.  Paroxysmal  pain  of  a  sharp  and  lancinating,  at 
times  heavy  and  dull  character,  following  the  course  of  the  ileo-hypo- 
gastric  nerve,  ileo-inguinal  and  external  spermatic  nerve,  supplying 
the  integument  of  the  hip,  the  inner  side  of  the  thigh,  the  scrotum 
and  labium. 

SCIATICA. 

Definition.  Pain  following  the  course  of  the  sciatic  nerve.  The 
sacral  plexus  is  made  up  of  the  fourth  and  fifth  lumbar  and  the  first 
two  pairs  of  sacral  nerves. 

Symptoms.  Sciatica  usually  follows  an  attack  of  lumbago,  the 
pain  becoming  fixed  in  the  sciatic  nerve  ;  at  times  it  is  a  true  neuritis. 
The  pain  is  sharp,  tearing,  shooting  or  lancinating  in  character,  in- 
creased upon  motion,  shooting  along  the  course  of  the  nerve  into  the 
hip,  inner  side  of  the  thigh,  half  of  the  leg,  ankle  and  heel,  at  one  or 
all  of  these  points,  in  paroxysms  lasting  from  a  few  hours  to  twenty- 
four  hours  or  longer.  The  tactile  sensation  in  the  foot  and  motility  in 
the  limbs  are  impaired,  and  if  of  long  duration,  wasting  of  the  limb 
occurs. 

Diagnosis.  Rheu7naiism,  so-called,  is  the  only  condition  likely 
to  be  confounded  with  neuralgia. 

The  history  of  the  attack,  the  character  of  the  pain,  with  its  local- 
ized spot  of  tenderness,  should  prevent  such  an  error. 

Prognosis.  If  promptly  and  properly  treated,  unless  the  result 
of  pressure  of  an  exostosis,  aneurism  or  other  tumor,  favorable. 


360  PRACTICE   OF   MEDICINE. 

•  Treatment  of  Neuralgia.  Rest ;  easily  assimilated  but  nutri- 
tious diet;  removal  of  the  cause,  if  possible.  If  anaemic, y^rrww  and 
arsenicum.  If  rheumatic,  alkalies.  If  syphilitic  or  the  result  of 
metallic  poisons,  potassii  iodidum.     If  malarial,  quinina. 

For  an  attack,  morphina  and  atropina,  hypodermically,  afford  the 
most  prompt  and  ready  relief. 

Success  usually  follows  the  use  of  the  well-known  "  Gross  (Prof.  S. 
D.)  neuralgic  pill:" — 

R,     Quinina  sulphas, gT- ij 

Morphince  sulphas. g"^*  ^V 

Strychninse, g""-  -jV 

Acidi  arseniosi, g'"-  5lr 

Extracti  aconiti,       %^-  \'  M. 

Ft.  pil.  No.  I. 

SiG. — One  every  one,  two  or  three  hours. 

Few  attacks  of  trigeminal  neuralgia  will  resist  the  following  powerful 
prescription : — 

R.     Aconitinae  (Duquesnel), g^- tV 

Glycerini, 

Alcoholis, aa  .    .    .    .  '7^\ 

Aquae  menth.  pip., ad ^  ij.  M. 

SiG. — Teaspoonful  repeated  from  four  to  eight  times  daily,  carefully 
watching. 

Facial  neuralgia  is  often  wonderfully  benefited  by  the  internal 
administration  oi  ext.  gelsemiifld.,  gtt.  iij-v,  every  three  or  four  hours, 
until  its  physiological  effects  are  produced.  Excellent  results  often 
follow  the  administration  of  Mb  us  sellers  pills  (s-comtine  andquininum). 

For  sciatica,  antipyrine,  gr.  xx,  repeated  two  or  three  times  daily, 
has  given  relief.  The  deep  injection  of  chloroformum  is  recommended 
by  Bartholow.  A  spray  oi  chloride  of  methyl  2i\ong  the  course  of  the 
nerve  for  a  few  moments,  watching  the  skin,  will  relieve  the  distress- 
ing pain.  Rarely  full  doses  potassii  iodidum  with  a  blister,  along  the 
course  of  the  nerve  gives  relief. 

All  forms  of  neuralgia  are  more  or  less  benefited  by — 

R.     Quininae  sulph., g^"-  iij 

P'erri  reflact, gr.  j 

Acid,  arsenious, g"*-  2V 

Aconitiae, gr.  j^g.         M. 

In  pill  every  four  or  five  hours. 


DISEASES   OF   THE    NERVES.  361 

The  following  formulae  of  Bardet  is  highly  recommended  for  all 
varieties  of  neuralgia  : — 

R.     Exalgine,     .    .    .    .    , ^j 

Spts.  rect., ^x 

Aq.  destil, ad ^v.  M. 

SiG. — One  to  three  tablespoonfuls  during  the  twenty-four  hours. 


FACIAL  PARALYSIS. 

Synonym.     Bell's  palsy. 

Definition.  An  acute  paralysis  of  the  seventh  cranial  or  facial 
nerve,  the  great  motor  nerve  of  the  muscles  of  the  face — the  nerve  of 
expression. 

Causes.  Exposure  to  a  current  of  cold  air  against  the  side  of  the 
face — over  the  pes  anserinus — is  the  most  frequent  cause.  Also  due 
to  injury  or  disease  of  the  middle  ear.     Syphilis. 

Symptoms.  The  facial  nerve  supplies  the  muscles  of  the  face, 
the  muscles  of  the  external  ear,  also  the  stylo-hyoid,  posterior  belly  of 
the  digastric,  the  platysma,  one  muscle  of  the  middle  ear,  the  stapedms, 
and  one  palate  muscle,  the  levator  palati ;  by  means  of  the  chorda 
tympani  branch  it  controls  the  secretion  of  the  parotid  and  submaxil- 
lary glands,  and,  possibly,  the  sense  of  taste.  It  also  furnishes  motor 
power  to  the  azygos  uvulse,  the  tensor  tympani  and  the  tensor  palati 
muscles. 

The  onset  is  usually  sudden,  with  tmgling  of  the  lips  and  tongue, 
and  upon  looking  into  the  mirror  the  patient  is  surprised  by  the  per- 
fectly blank,  motionless  side  of  the  face,  the  corner  of  the  mouth  is 
depressed,  the  eyelids  open,  the  face  drawn  toward  the  well  side,  and 
with  inability  to  expectorate,  whistle  or  swallow. 

Any  of  the  muscles  innervated  by  the  nerve  may  participate  in  the 
paresis. 

The  electro-co7tiractility  is  feeble  or  lost.  The  reflexes  are  abolished. 

Diagnosis.  Paralysis  of  the  muscles  of  the  face  occurs  in  hemi- 
plegia ;  the  points  of  differentiation  are  the  presence  of  cerebral 
symptoms  and  the  normal  reflex  excitability. 

Facial  palsy  with  otorrhcea,  imperfect  hearing,  obliquity  of  the 
uvula  and  loss  of  taste  determine  its  origin  within  the  aquaeductus 
Fallopii. 

It  is  the  result  of  cold  if  the  taste  be  normal  and  the  uvula  straight. 
30. 


3(12  PRACTICE   OF   MEDICINE. 

,  If  Other  nerves  are  also  involved  the  origin  is  central. 

Prognosis.     Favorable. 

Treatment.  If  the  result  of  cold  and  damp,  diaphoresis  with 
pilocarpus,  or  diuresis  with  potassii  acetas,  vel  iodidian,  and  blisters 
in  front  of  ear,  and  the  use  oi  galvanism  to  the  affected  muscles. 


DISEASES  OF  THE  BLOOD. 


ANEMIA. 

Synonyms.     Spanaemia ;  hydraemia. 

Definition.  A  deficiency  of  red  corpuscles  and  albuminoid  com- 
pounds— a  poverty  of  the  blood  ;  characterized  by  pallor  and  general 
weakness. 

OligcEjnia  is  a  lessening  in  the  amount  of  blood ;  Ischcsmia  is  a 
localized  anaemia. 

Causes.     Predisposing  and  exciting. 

Predisposijtg.  Sex  ;  the  female,  pregnancy  and  menopause ; 
heredity. 

Exciting.  Deficient  food,  air  or  sunshine ;  excessive  work ;  mental 
worry  ;  prolonged  and  frequent  nocturnal  emissions  ;  excessive  nurs- 
ing ;  chronic  intestinal  catarrh  ;  Bright's  disease  ;  malaria. 

Pathological  Anatomy.  Post-inortem,  the  tissues  are  thin, 
shrunken  and  bloodless.  If  the  anaemia  has  been  of  long  duration, 
patches  of  fatty  change  are  seen  in  the  various  organs.  The  blood 
has  a  brighter  color,  the  result  of  diminution  in  the  number  of  red 
corpuscles  and  the  quantity  of  the  haemoglobin  ;  it  is  thinner  than 
normal,  and  coagulates  slowly  and  imperfectly,  from  diminution  of 
the  fibrino-plastic  constituent. 

Symptoms.  Pallor,  gums,  tongue,  ear  and  conjunctiva  pale. 
Muscular  weakness,  inability  for  exertion.  Deficient  appetite  and 
impaired  digestion,  attacks  of  vomiting,  the  result  of  anaemia  of  the 
medulla  oblongata.  Quickened  respiration,  irritable  temper,  vertigo 
in  the  erect  position,  attacks  oi  swooning,  hysteria,  and  rarely  epilepsy. 
Irritable  heart,  with  soft  systolic  basic  muntiurs  and  attacks  of  hysteria. 
Nocturnal  emissions  in  male  and  deficient  menses  in  female.    Maras- 


DISEASES   OF  THE  BLOOD.  363 

mi^s  in  children.  More  or  less  general  cedema  of  the  eyelids  and 
ankles.  Long  continued,  symptoms  of  fatty  changes  in  various 
organs  or  gastric  ulcer  result. 

Diagnosis.  The  symptoms  of  anaemia  are  so  characteristic  that 
an  error  is  impossible ;  the  cause  of  it,  however,  may  be  hidden. 

Prognosis.  Favorable  if  treated  early.  If  protracted,  results  in 
more  or  less  general  symptoms  of  fatty  degenerations  or  ulcer  of  the 
stomach. 

Treatment.  Remove  the  cause.  Easily  assimilated,  blood-pro- 
ducing diet.  Fresh  air,  sunlight  rind  exercise  short  of  fatigue.  Purga- 
tives with  stomachic  tonics,  to  promote  digestion. 

For  the  anaemia  proper,  ferrujn  in  some  form  is  the  most  valuable 
remedy,  always  remembering  that  it  is  not  assimilated  if  the  intestines 
and  liver  be  torpid. 

The  following  alterative  tonic,  known  as  Smith's  (Dr.  A.  H.)  '*  four 
chlorides,"  is  frequently  of  value: — 

R.     Hydrargyri  chloridi  corrosivum,      ......    gr.  j-ij 

Liq.  arsenici  chloridi, f^j 

Tinct.  ferri  chloridi, 

Acidi  hydrochlorici  dil.,   .    .    .    .  aa  .    .    .    .  f^iv 

Syrupi,   „ f^iij 

Aquae, ad f^YJ-  M. 

SiG. — One  dessertspoonful  in  a  wineglassful  of  water  after  each  meal. 

Cases  of  anemia  with  weak  stomach  can  take  the  following  "  iron 
lemonade"  with  ease: — 

li .     Tinct.  ferri  chloridi, f  ^  j 

Acid,  phosphor,  dil.,     . f^ij 

Syr.  limonis, f,f  jss 

Aquae, , f  J  ij-  M. 

SiG. — One  teaspoonful  well  diluted. 


CHLOROSIS. 

S3nionyni.    Green  sickness. 

Definition.  A  pronounced  anaemia,  occurring  in  girls  about  the 
age  of  puberty. 

Causes.  Obscure;  inherited;  menstrual  irregularities.  Ham- 
mond maintains  "that  it  is  an  affection  of  the  nervous  system,  the 
blood  changes  being  secondary." 


364  PRACTICE   OF   MEDICINE. 

Pathological  Anatomy.  The  blood  is  deficient  in  red  cor- 
puscles, the  vokime  of  the  fluid  normal  or  nearly  so.  Rarely  the 
mass,  of  blood  is  increased.  The  body  is  well  nourished  and  the  sub- 
cutaneous fat  well  distributed.  The  organs  are  abnormally  pale. 
The  spleen,  the  lymphatics  and  the  marrow  of  the  bones  are  not 
affected  in  any  manner. 

Symptoms.  The  condition  is  associated  with  disorders  of  men- 
struation. The  young  girl  experiences  a  chajige  of  disposition,  becom- 
ing morose  and  despondent,  or  rarely  hysterical. 

"As  respects  the  actual  condition  of  the  sexual  organs,  there  are 
two  forms  of  derangement  which  happen  in  chlorosis  ;  there  are  the 
amejiorrhcEic  form  and  the  inenorr]iagic  form."  After  an  attack  of 
menorrhagia  or  after  the  failure  of  the  flow  to  appear,  the  changes 
occur.  The  complexion  changes,  blondes  becoming  pallid,  waxy  and 
puffy  without  oedema ;  brunettes  becoming  muddy  and  grayish  in 
color,  with  bluish-black  rings  under  the  eyes.  Weariness  and  fatigue 
upon  the  least  exertion  ;  the  heart  irritable,  with  shortness  of  breath. 
The  appetite  is  vitiated,  the  digestion  imperfect;  attacks  of  gastralgia 
are  frequent. 

A  not  infrequent  complication  is  gastric  ulcer.  Phthisis  develops  in 
those  having  the  slightest  predisposition. 

Prognosis.  As  a  rule,  unfavorable,  on  account  of  the  liability 
to  grave  complications.  Those  recovering  are  always  liable  to 
relapses. 

Treatment.  A  generous,  nutritious  diet ;  fresh  air ;  moderate 
exercise ;  change  of  scene ;  cheerful  surroundings.  Ferruin  and 
arsenicum  are  of  the  greatest  utility.     A  good  combination  is — 

H .     Ferri  arseniatis,       gr.  ^^-\ 

Ext.  nucis  vomicse,    .    , gr.  \-\.  M. 

Ft.  pil.  No.  I. 
SiG. — After  meals. 

The  following  is  Bland's  formula,  so  highly  lauded  by  Niemeyer: — 

R.      Pulv.  ferri  sulph., 

I'oiassii  carbonat.  puroe,    .    .    .  aa ^^ss 

Tragacanthce, q.  s.  M. 

Ft.  pi.  No.  xcvj. 

SiG. — One  to  three  or  four  pills  three  times  daily. 


DISEASES   OF   THE    BLOOD.  365 

PROGRESSIVE  PERNICIOUS  ANEMIA. 

Synonyms.  Anaematosis ;  essential  anaemia;  anaemia  of  fatty 
heart. 

Definition.  A  pernicious,  progressive  form  of  anaemia,  of  unknown 
cause,  resisting  all  treatment,  and  toward  its  termination  associated 
with  fever. 

Pathological  Anatomy.  The  blood  is  scanty  and  pale,  with 
diminished  red  corpuscles,  albuminates  and  fibrin,  showing  a  very 
feeble  tendency  to  coagulate.  There  is  no  increase  in  the  white 
corpuscles. 

The  marrow  in  adult  bones  becomes  foetal,  red  and  adenoid,  and 
contains  microcytes  ;  several  other  changes  have  occurred  second- 
arily in  the  marrow. 

Secondary  to  the  anaemia,  the  heart,  larger  arteries  and  certain 
capillary  tracts  exhibit  circumscribed  or  diffused  fatty  degeneration. 

The  liver,  spleen,  kidneys  and  stomach  are  decidedly  anaemic, 
causing  fatty  changes  in  those  organs.  The  skin  may  contain  pete- 
chiae  of  a  purplish  or  brownish  tint,  and  internal  hemorrhages  are  not 
infrequent ;  retinal  hemorrhage  is  rarely  wanting. 

There  is  not  much  emaciation,  though  the  pallor  is  pronounced. 

Symptoms.     It  begins  insidiously,  with  increasing  languor  and 

pallor,  the  muscular  weakness  compelling  the  patient  to  take  his  bed. 

Cardiac  palpitation,  dyspncea,  attacks  oi  syncope,  oede7na  and  swelling 

about  the  ankles,  with  petechial  spots  scattered  irregularly  over  the 

surface. 

The  appetite  is  waning,  and  nausea  and  vomiting  occur,  associated 
with  marked  dyspepsia  and  persistent  diarrhoea.  As  the  disease  pro- 
gresses a  remittent  form  oi  fever  develops,  the  temperature  frequently 
showing  102-104°  F. 

Disorders  of  vision  are  the  result  of  the  retinal  hemorrhage.  The 
cardiac  sounds  are  feeble  and  associated  with  soft  basic  or  anaemic 
murmurs. 

Diagnosis.  Progressive  pernicious  anaemia  is  distinguished  from 
simple  anaemia  and  chlorosis  by  the  greater  severity  of  the  former. 
From  leucocythemia  by  the  normal-sized  spleen  and  liver,  and  the 
absence  of  increase  in  the  white  corpuscles. 

Prognosis.     Unfavorable. 

Treatment.    Symptomatic. 


366  PRACTICE   OF   MEDICINE. 

LEUCOCYTHEMIA. 

S37Tlonyins.  Leucaemia;  white  cell  blood  ;  white  blood;  anaemia 
splenica. 

Definition.  A  condition  in  which  there  is  an  enormous  increase 
in  the  number  of  white  blood  corpuscles.  It  may  assume  either  a 
splenic,  a  lymphatic,  or  a  myelogenic  form,  and  is  characterized  by 
symptoms  of  pronounced  anaemia. 

Causes.  The  real  cause  and  nature  of  the  affection  is  un- 
known. 

Pathologrical  Anatomy.  The  spleen  is  increased  in  size, 
density  and  firmness ;  the  lymphatic  glands  all  over  the  body  also 
enlarge,  but  are  soft  to  the  touch,  often  fluctuating  ;  the  ^narrow  of 
the  bones  changes  from  its  normal  rose  color  to  that  of  a  greenish- 
yellow  ;  the  liver  also  enlarges  enormously.  The  blood  is  paler  than 
normal,  its  specific  gravity  reduced  1.055  to  1.040  or  lower,  and  the 
white  corpuscles  increased  in  number  and  in  size,  the  red  corpuscles 
being  lessened  in  number  and  size. 

Symptoms.  The  onset  and  early  progress  of  the  disease  is  iden- 
tical with  that  of  simple  anaemia,  accompanied  by  swelling  oi  the 
abdomen  and  a  feeling  o{  fullness  and  pain  in  the  splenic  region,  due 
to  enlargement  of  that  organ. 

In  the  lymphatic  variety,  enlargement  of  the  glands  in  the  groin, 
neck  and  axillary  region  are  associated  with  \.h.Q  great  pallor. 

In  the  myelogenic  variety,  the  bones,  more  particularly  the  ribs  and 
sternum,  are  tender  on  pressure,  the  patient  developing  a  waxy  ap- 
pearance. 

In  each  variety  the  appetite  is  poor,  the  digestion  feeble,  the  bowels 
loose,  the  patient  easily  fatigued,  with  cardiac  palpitation,  and  dysp- 
noea, with  oedema  of  the  eyelids  and  ankles.  The  urine  is  scanty  and 
of  high  specific  gravity — i. 020-1. 030. 

Diagnosis.  This  should  cause  but  little  trouble  if  enlarged  spleen, 
lymphatic  glands  and  tender  bones  are  associated  with  great  pallor, 
and  the  characteristic  appearance  of  the  blood  as  demonstrated  by  a 
"  puncture  of  the  finger  of  the  patient  and  receiving  the  blood  on  a 
piece  of  white  linen  or  a  lawn  handkerchief,  and  placing  by  the  side 
of  it  a  similar  stain  of  blood  from  a  healthy  subject.  The  full  color 
of  the  latter  contrasts  strikingly  with  the  stain  of  the  former,  which 
is  hardly  of  a  blood  color  and  translucent." 


DISEASES   OF  THE   BLOOD.  367 

Prognosis.  No  case  of  recovery  has  yet  been  recorded.  The 
average  duration  is  between  two  and  three  years. 

Treatment.  Symptomatic.  A  combination  of  the  following  rem- 
edies with  generous  diet,  fresh  air,  sunshine,  pleasant  surroundings, 
oleum  morrhncB  and  the  hypophosphites  have  at  times  seemed  of 
temporary  utility,  to  wit :  quinina,  arsenicum,  ferru7n  and  ergota. 


ADDISON'S  DISEASE. 

Synonym.     Melasma  supra-renalis. 

Definition.  "The  bronzed-skin  disease."  Thus  defined  byAver- 
beck  :  "A  well-marked  constitutional  disease,  exhibiting  itself  locally 
as  a  chronic  inflammation  of  the  supra-renal  capsules,  but  in  its 
essence  consisting  in  a  peculiar  anaemic  condition,  always  tending 
toward  death,  which  is  characterized  by  intense  development  of  pig- 
ment in  the  cells  of  the  rete  malpighii  and  in  the  epithelium  of  the 
mucous  membrane  of  the  mouth." 

Causes.  Uncertain.  Tubercle,  scrofula  and  syphilis  have  each 
been  given  as  the  cause. 

Pathological  Anatomy.  A  low  form  of  inflammation,  termi- 
nating in  degeneration  of  the  supra-renal  capsule.  The  blood  is 
deficient  in  fibrin  and  red  corpuscles,  with  a  slight  increase  of  the 
white  corpuscles.  Fatty  degeneration  of  the  heart  and  vessels  has 
been  observed  in  some  cases. 

"The  most  striking  change  during  life — the  abnormal  pigmenta- 
tion— is  due  to  the  deposition  of  granular  pigment  in  the  cells  of  the 
rete  malpighii,  in  the  papillary  portion  of  the  cutis,  and  even  in  the 
connective  tissue  corpuscles.  No  change  occurs  in  the  proper  struc- 
ture of  the  skin.  Similar  pigment  deposits  occur  in  the  mucous  mem- 
brane of  the  mouth,  especially  along  the  edges  of  the  teeth." 

"The  disease  of  the  supra-renal  capsules  excites  an  irritation  of 
the  vaso-motor  system — the  trophic  system — which  leads  to  the  pig- 
mentation." 

Symptoms.  The  onset  of  the  disease  is  insidious,  with  a  feeling 
of  extreme  languor,  muscular  fatigue ,  asthenia,  indigestion,  anorexia, 
dyspnoea,  cardiac  palpitation,  vertigo,  melancholia  and  excessive 
drowsiness. 

The  surface  is  first  pale,  then  changes  to  a  hue  like  that  of  melan- 
CEtnia,  changing  to  icteroid,  finally  resembling  the  color  of  a  mulatto, 


368  PRACTICE   OF   MEDICINE. 

and  then  to  a  lustreless  bronze.     These  changes  also  occur  on  the 
mucous  membrane  of  the  lips,  tongue,  gums  and  mouth. 

Prognosis.     An  incurable  disease.     Duration,  a  year  or  two. 

Treatment.     Symptomatic. 


HAEMOPHILIA. 

Synonyms.     Hemorrhagic  diathesis  ;  "  bleeders' disease." 

Definition.  A  congenital  condition  characterized  by  the  habitual 
occurrence  of  hemorrhages. 

Cause.     Hereditary. 

Symptoms.  The  bleeding  appears  about  the  period  of  first 
dentition,  and  consists  of  spontaneous  hemorrhages  from  the  mucous 
membrane  of  the  nose,  mouth,  lungs,  stomach,  intestines,  or  genito- 
urinary passages,  or  in  perfect  cases,  hemorrhages  occur  directly  from 
the  fingers,  toes,  lobes  of  the  ears,  back  of  the  hands  or  arms,  without 
any  apparent  change  in  the  skin,  and  continue,  in  spite  of  the  most 
powerful  means,  for  days  or  weeks.  Traumatic  hemorrhages  occur  if 
an  injury  of  any  kind  is  sustained  about  the  period  of  the  develop- 
ment of  the  bleeding. 

Epistaxis  is  the  most  common  form  of  all  those  named. 

As  a  result  of  the  great  loss  of  blood,  the  subject  suffers  from  all 
the  symptoms  of  profound  anaemia. 

Diagnosis.  It  is  impossible  to  confound  the  "  bleeders'  disease  " 
with  any  other  affection. 

Prognosis.  Death  is  the  usual  termination  within  a  few  weeks 
from  the  time  of  its  development,  which  may  not  be  until  adult  Hfe. 

Treatment.  Entirely  symptomatic.  It  is  claimed  that  " potassii 
chloras — an  ounce  of  a  saturated  solution  three  times  a  day — com- 
bined with  tinctura  ferri  chloridi,''  WiW  eradicate  the  constitutional 
tendency. 

SCORBUTUS. 

Synonym.     Scurvy. 

Definition.  A  peculiar  condition  of  malnutrition  or  anaemia, 
gradually  developing  upon  a  dietary  deficient  in  fresh  vegetable 
material;  characterized  by  decided  anaemia,  debility,  mental  lethargy, 
petechiae  and  a  swollen  and  spongy  state  of  the  gums,  with  a  ten- 
dency to  bleed  upon  the  slightest  irritation. 


DISEASES   OF  THE   BLOOD.  369 

Causes.  The  disease  only  occurs  when  fresh  vegetable  nutriment 
or  some  appropriate  substitute  has  been  for  a  time  partially  or  com- 
pletely withheld. 

Patholog'ical  Anatomy.  An  undetermined  derangement  in 
the  composition  of  the  blood,  with  diminished  proportion  of  the 
potash  salts.  Spleen  enlarged.  The  tissues  are  wasted  and  present 
extravasations,  due  to  either  one  of,  or  the  combined  presence  of,  the 
following  conditions,  to  wit :  liquid  condition  of  the  blood,  allowing 
it  to  escape  from  the  vessels,  alterations  in  the  walls  of  the  vessels,  or 
a  vaso-motor  paralysis. 

Symptoms.  General  weakness,  lassitude,  indisposition  to  either 
mental  or  physical  exertion.  The  skin  is  dry,  rough  and  of  a  muddy 
pallor,  the  face  pale  and  bloated.  Swelling  and  sponginess  of  the 
gums,  with  great  tendency  to  bleed  and  an  exceedingly  offensive 
breath.  Looseness  of  the  teeth,  hemorrhages  from  mucous  surfaces, 
and  extravasations  of  blood  within  and  beneath  the  skin.  The  lips 
are  pale,  which  is  in  striking  contrast  to  the  redness  of  the  gums  ;  the 
ey^s  are  sunken  and  surrounded  by  a  dark  blue  circle. 

Hemorrhages  occur  from  the  stomach,  mouth,  bronchial  tubes, 
intestinal  canal  and  vagina.  The  skin  is  dry  and  rough,  resem- 
bling that  of  a  plucked  fowl.  QEdema  of  the  face  and  ankles  not 
infrequent. 

Depression  of  the  spirits  is  characteristic.  Palpitation  and  dyspnoea 
on  exertion.    Urine  high  colored,  speedily  becoming  fetid. 

The  patient  usually  longs  iox  fresh  vegetables  dund.  fruits. 

Com.plications.  Dysentery.  Scorbutic  dysentery  is  a  frequent 
complication.     It  may  co-exist  with  typhoid  and  typhus  fever. 

Prog'nosis.     Favorable,  if  early  and  properly  treated. 

Treatm.ent.  The  chief  indication  is  the  assimilation  of  the  ali- 
mentary principles  needed  for  the  healthy  constitution  of  the  blood 
and  the  invigoration  of  the  system. 

The  juice  of  lemons,  oranges  and  other  fruits.  Antiscorbutic  vege- 
tables, to  wit:  raw  cabbage,  cresses  and  raw  potatoes,  in  conjunction 
with  meats,  milk  and  farinaceous  food. 

Improve  the   appetite   and   digestion   by  the   use   of   strychnina, 
quinina,  mineral  acids  and  bitter  infusions.     Potassii  chloras,  locally, 
will  relieve  the  oral  symptoms. 
31 


370  PRACTICE   OF   MEDICINE. 

PURPURA. 

Synonym.     Hemorrhoea  petechialis. 

Definition.  An  acute  disease,  characterized  by  purplish  discol- 
orations  of  the  skin,  the  result  of  hemorrhages  into  the  upper  layers 
of  the  cutis  and  beneath  the  epidermis. 

Varieties.  Purpura  simplex  ;  purpura  hemorrhagica  ;  purpura 
urticans. 

Causes.  Not  properly  understood.  It  may  occur  at  any  age, 
but  is  especially  frequent  in  children  and  elderly  people.  Its  occur- 
rence after  the  ingestion  of  certain  articles  of  diet  has  been  observed. 

Symptoms.  Purpura  simplex  is  the  mildest  form  of  the  afifection, 
and  is  characterized  by  the  sudde?t  appearance  of  s?)iaii,  bright  red 
spots — a  cutaneous  hemorrhage — most  commonly  on  the  legs,  asso- 
ciated with  slight  lassitude,  mild  febrile  reaction,  and  aching  pains  in 
the  limbs.  The  hue  of  the  spots  rapidly  fades  to  a  purplish  color  and 
slowly  disappears.     Relapses  are  common. 

Purpura  hemorrhagica  has,  in  addition  to  the  eruption  of  purpura 
simplex — the  cutaneous  hemorrhage — a  flow  of  blood  from  the  free 
surface  of  mucous  membranes.  The  most  common  hemorrhage  is 
epistaxis,  slight  or  profuse.  Other  hemorrhages  are  hcsmateviesis, 
malcena,  hcsmaturia,  hcB?noptysis,  7nenorrhagia,  and  also  into  the  sub- 
stance of  the  mucous  membranes  of  the  palate,  cheeks  and  gums. 
This  variety  is  associated  with  great  debility  and  depression,  moderate 
fever  and  disorders  of  digestion.  Marked  ancemia  results  from  the 
hemorrhages. 

Purpura  urticans  is  a  combination  of  urticaria  and  purpura  sim- 
plex. It  is  characterized  by  "  rounded  and  reddish  elevations  of  the 
cuticle,  resembling  wheals,  but  which  are  not  accompanied,  like  the 
wheals  of  urticaria,  by  any  sensation  of  itching  or  tingling."  They 
are  usually  seated  on  the  legs,  thighs,  breast  and  arms,  and  are  inter- 
spersed with  petechiiE.  They  gradually  form  and  subside  within 
twenty-four  or  thirty-six  hours.     Relapses  are  frequent. 

This  variety  is  also  associated  with  malaise,  moderate  fever,  and 
pains  in  the  limbs. 

Prognosis.  Purpura  simplex  and  purpura  urticans  are  favorable, 
but  relapses  are  very  frequent.  Purpura  hemorrhagica  is  always  a 
grave  disease,  often  proving  fatal  from  exhaustion,  or  more  rarely 


DISEASES    OF   THE   SKIN.  371 

cerebral  or  pulmonary  hemorrhage.  Recovery  occurs  frequently, 
under  judicious  treatment. 

Treatment.  Rest  and  a  concentrated  nutritious  diet,  and  the 
moderate  use  of  stimulants,  to  combat  the  resulting  anaemia. 

The  internal  use  of  oleum  terebitithince  is  one  of  the  most  reliable 
remedies  for  all  forms  of  the  disease.  The  following  is  an  eligible 
formula  : — 

R.     01.  terebinthinae, f^^^ij 

01.  amygdalae  express.,     .    . f^j 

Tinct,  opii  deodorat., ■.    .    .    .  fgss 

Mucil.  acacite, ^5J 

Aq.  lauro-cerasi, - f  ^  iij,  M. 

SiG. — One  teaspoonful  every  three  or  four  hours. 

Among  the  other  numerous  remedies  suggested,  the  most  reliable 
have  been  acidtwi  sulphur icimi  dilutum  2ir\d  tinctura  ferri  chhridi. 
Good  results  have  followed  acidum  carbolicwn,  gtt.  ij-iij  every  three 
hours,  in  cases  seen  by  the  author,  and  a  particularly  persistent  case 
was  cured  by  full  doses  of  potassii  iodidum. 

"  If  hemorrhages  that  are  threatened  come  on  with  a  strong  pulse, 
flushed  face,  headache  and  excitement,  digitalis,  quinitia  and  ergota 
are  the  approximate  medicaments."     (Bartholow.) 

Locally,  to  arrest  bleeding,  astringents  and  either  hot  or  cold  water 
or  ice. 


DISEASES  OF  THE  SKIN. 


DISORDERS    OF  SECRETION. 

SEBORRHCEA. 

Synon3niis.  Acne  sebacea ;  pityriasis  ;  tinea  furfuracea ;  dan- 
druff. 

Definition.  A  functional  disorder  of  the  sebaceous  glands  of  the 
skin ;  characterized  by  an  excessive  and  abnormal  secretion  of  seba- 
ceous matter,  forming  upon  the  skin  either  as  an  oily  coating,  or  in 
crusts  and  scales. 

Varieties.     Seborrhasa  oleosa  ;  seborrhcea  sicaa. 


372  PRACTICE    OF    MEDICINE. 

Causes.  In  newly-born  infants  an  increased  secretion  of  seba- 
ceous matter — the  vernix  caseosa — is  a  physiological  process. 

The  origin  of  the  disease  is  for  the  most  part  illy  understood, 
anaemia  being  a  factor  in  many  cases. 

Pathology.  Seborrhoea  is  a  functional  derangement  of  the 
glands  ;  if  it  be  allowed  to  become  very  chronic,  there  occurs  atrophy 
of  the  glands  and  follicles. 

Symptoras.  The  affection  may  occur  upon  any  portion  of  the 
body,  its  most  frequent  seat  being,  however,  the  scalp  {seborrhoea 
capitis  ox  pityriasis  capitis),  and  next  in  frequency  the _/h;^^  {seborrhoea 
faciei). 

Seborrhoea  oleosa ;  appears  as  an  oily,  greasy  coating  upon  the 
skin,  without  hyperaemia,  and  not  attended  with  itching.  The  secre- 
tion is  of  an  oily  character,  the  quantity  at  times  being  so  great  as  to 
collect  in  minute  drops  of  a  clear,  yellowish  fluid  upon  the  surface. 

The  most  common  seat  for  this  variety  is  the  face — seborrhosa  faciei 
— and  nose — seborrhoea  ?iasi. 

Seborrhoea  sicca,  consists  in  the  formation  of  dry,  more  or  less 
greasy  inasses  of  scales  or  crusts  of  2i  grayish,  yellowish,  or  brownish- 
yellow  color,  having  a  strong  tendency  to  adhere  to  the  skin,  and 
attended  with  decided  itching.  Occurring  upon  the  scalp — seborrhoea 
capitis — it  is  a  frequent  source  of  pretnature  baldness. 

Diagnosis.  Seborrhoea  capitis  may  be  mistaken  for  dry  eczema, 
but  the  former  is  always  a  dry  disease,  while  in  eczema  moisture  has 
occurred  at  some  period  of  the  affection.  The  scales  in  seborrhoea 
are  very  abundant  and  pale ;  in  eczema  the  scales  are  scanty  and 
reddish,  the  parts  irritated,  infiltrated  and  thickened. 

Seborrhoea  sicca  and  psoriasis  have  many  points  of  resemblance, 
whether  occurring  on  the  scalp  or  on  the  body.  In  seborrhoea  the 
scales  are  minute  or  caked,  grayish  or  yellowish  in  color,  of  an  unctuous 
feel  and  usually  uniformly  diffused.  In  psoriasis  the  scales  are  very 
dry,  abundant,  thick,  white,  irregularly  dispersed,  with  intervening 
healthy  skin,  and  the  surface  beneath  the  scales  is  always  reddish  a?id 
inflamed.     The  clinical  histories  of  the  diseases  are  entirely  different. 

Prognosis.  If  properly  treated,  favorable,  although  the  affection 
is  obstinate  to  eradicate.  ' 

Treatment.  The  secretions  require  attention.  If  anaemia  be 
present, /t'/'r/^w  and  arsenicum  are  indicated.  The  following  formula 
of  Sir  Erasmus  Wilson,  and  lauded  by  Hebra,  is  valuable  : — 


DISEASES   OF  THE  SKIN.  373 

R  .     Vini  ferri, ^ d  ^^^ 

Syr.  simplex, 

Liquor  potassii  arsenit.,    .    .    .  aa ^ij 

Aqu£e  destil., f^ij-  M. 

SiG. — Teaspoonful  three  times  a  day,  with  meals. 

Duhring  recommends  calcii  sidphid.,  gr,  xq-\,  several  times  daily. 

Local  measures  are  the  most  important  in  seborrhoea.  For  sebor- 
rhcea  capitis  the  following  plan  will  usually  be  successful : — 

The  scales  are  to  be  thoroughly  moistened  with  either  oleum  oHvcb, 
oleum  morrhuce,  or  adeps,  to  facilitate  their  removal ;  it  is  best  applied 
at  night  and  the  head  covered  with  a  flannel  or  other  cap.  As  soon 
as  the  crusts  are  well  soaked  they  should  be  removed  by  washing 
with  soap  and  warm  water,  or  equal  parts  of  soap,  glycerine  and 
water,  or  the  following  will  be  found  valuable : — 

R.     Saponis  viridis  (Hebra), f^i'^ 

Spts.  vini  rect., f^ij- 

Solve  et  filtra. 
SiG. — Dilute  and  use  as  a  soap- wash  or  shampoo. 

The  scalp  is  to  be  thoroughly  cleansed  of  either  of  the  above  by 
again  washing  with  warm  water  and  then  dried  by  means  of  soft 
towels.  Then  should  be  applied  some  oily  or  fatty  substance  depend- 
ing upon  the  condition  of  the  scalp. 

If  much  irritation,  either  vaseline  or  oleum  amygdalce  expressum. 
If  no  irritation  be  present,  a  stimulating  preparation  will  be  found  of 
great  benefit.     Either  of  the  following  may  be  used  : — 

R  .     Tinct.  cantharidis, f  3  "J 

Tinct.  capsici, f^iij 

Ol.  ricini, f.^^ij 

Alcoholis, f,^ij 

Spts.  rosmarini, .    .    .    .  f  Jj.  M. 

— Duhring. 
Or— 

R  .     Bismuthi  subnitratis, f  ^  j 

Ung,  hydrargyri  ammon., 3ij~^^ 

Ung.  aquae  rosae, ad %\.  M. 

The  above  should  be  repeated  every  day  or  two,  as  the  symptoms 
may  require,  until  a  cure  is  effected. 


374  PRACTICE   OF   MEDICINE. 

The  following  combination  is  useful  for  dandruff: — 

R .     Ammonii  muriat., gr-  x 

Glycerin^e, f,5J 

Aq.  rosje, ^y.  M. 

SiG. — Apply  to  head. 

The  seborrhoea  of  other  portions  of  the  body  are  to  be  treated  upon 
the  same  general  principles. 

COMEDO. 

SjTTionjTTQS.     Acne  punctata  nigra  ;  black  heads  or  worms. 

Definition.  A  disorder  of  the  sebaceous  glands;  characterized 
by  retention  in  the  excretory  ducts  of  an  inspissated  secretion  which 
is  visible  upon  the  surface  as  yellowish  or  whitish  pin-point  and  pin- 
head-sized  elevations,  containing  in  their  centre  blackish  points. 

Causes.  The  true  etiology  is  unknown.  Among  the  causes 
assigned  are,  anaemia,  menstrual  disorders,  urethral  irritations,  dys- 
pepsia and  constipation. 

Patholog'y.  Comedo  is  an  affection  of  the  sebaceous  glands  and 
ducts,  consisting  of  an  accumulation  of  sebum  and  epithelial  cells  in 
the  glands  and  follicles,  dilating  the  ducts  to  such  an  extent  as  to  pro- 
duce the  point  or  elevation  upon  the  surface.  The  obstructed  gland 
may  relieve  itself,  or  it  may  continue  distending  until  a  papule  is 
formed.  The  duct  sometimes  contains  small  hairs,  and  also  the  micro- 
scopic mite — demodex  folUciiloyu})i — having  a  length  of  from  yi^  to 
TjJ-  of  an  inch,  and  breadth  of  about  ^^jy  of  an  inch,  which  was  at  one 
time  erroneously  supposed  to  be  the  cause  of  the  affection. 

Symptoms.  Essentially  a  chronic  affection,  observed  for  the 
most  part  on  the  face,  neck,  chest  and  back.  Each  single  elevation 
or  black-head  or  point  is  designated  a  comedo,  or  if  a  number,  in  the 
plural,  as  comedones. 

Each  comedo  is  small,  varying  from  a  pin-point  to  a  pin-head  in 
size,  having  a  brownish  or  blackish  appearance,  from  the  dust  or 
dirt  that  has  adhered  to  their  unctuous  surface.  \{  they  form  in  great 
numbers  upon  the  face  they  are  disfiguring,  giving  the  individual  the 
appearance  of  having  had  minute  grains  of  powder  implanted  in  the 
skin.  There  are  no  evidences  of  inflammation  unless  acne  is  asso- 
ciated, but,  on  the  contrary,  the  skin  has  a  dirty,  greasy,  unwashed, 
appearance. 


DISEASES   OF   THE   SKIN.  375 

Diagnosis.  There  is  no  condition  resembling  comedo,  so  that 
its  recognition  is  easy,  unless  complicated  with  acne ;  but  even  then 
the  inflammatory  appearance  of  acne  should  prevent  an  error. 

Prognosis.     Favorable,  although  often  remarkably  obstinate. 

Treatment.  Derangements  of  any  of  the  functions  of  the  body 
should  be  corrected,  and  strict  attention  be  given  to  the  rules  for  pro- 
moting the  general  health. 

Local  measures  are  usually  sufficient  to  promote  a  cure  of  the 
affection. 

The  parts  affected  should  be  thoroughly  softened  by  bathing  with 
soap  and  warm  water,  when  the  comedones  are  removed  by  friction 
with  a  Turkish  towel,  pressure  between  the  thumb  nails,  the  appli- 
cation of  a  watch  key,  or  the  instrument  known  as  the  "  comedo 
extractor,"  and  their  return  prevented  by  an  unguentutn  medicated, 
to  meet  the  indications,  with  either  sulphur,  alkalies,  or  hydrargy- 
rum. 

Piffard's  acne  application  I  have  found  valuable  : — 

Jje .     Sulphur  sublim., 

^Icoholis, 

Tinct.  lavend.  comp., 

Glycerini, 

Aquae  camphorse, aa f^j-  M- 

SiG. — Apply  freely,  after  removal  of  the  comedones. 

MILIUM. 

Synonyms.  Grutum  ;  tubercula  miliaria  or  sebacea ;  acne  punc- 
tata albida. 

Definition.  An  accumulation  of  sebum  in  the  sebaceous  glands 
which  are  minus  their  excretory  ducts  ;  characterized  by  the  forma- 
tion of  small,  roundish,  whitish,  sebaceous,  non-inflammatory  eleva- 
tions, situated  immediately  beneath  the  epidermis. 

Cause.     The  origin  of  the  affection  is  not  understood. 

Pathology.  The  sebaceous  gland  is  distended  with  the  sebum, 
which  is  unable  to  escape  owing  to  the  obliteration  of  the  duct,  nor 
can  the  contents  be  squeezed  out,  as  no  sign  of  aperture  is  to  be 
found,  the  formation  being  completely  enclosed. 

Rarely  the  retained  secretion  undergoes  a  metamorphosis  into  hard, 
calcareous,  stone  like  masses — sebaceous  concretions  or  cutaneous 
calculi. 


376  PRACTICE   OF   MEDICINE. 

Symptoms.  Milia  may  occur  upon  any  portion  of  the  body  ; 
their  usual  seat,  however,  is  upon  the  face,  forehead,  and  about  the 
eyes.  They  form  gradually,  are  about  the  size  of  a  millet  seed,  of  a 
whitish,  pearl  or  yellowish  color,  hard,  and  of  a  rounded  shape,  giv- 
ing the  sensation  to  the  touch  of  hard  bodies  embedded  in  the  skin. 
They  are  not  associated  with  injflammatory  symptoms. 

Diagnosis.  Milium  and  comedo  are  somewhat  similar  in  ap- 
pearance ;  the  differences  are  that  in  milium  the  sebaceous  gland  is 
distended  without  an  opening,  while  in  comedo  the  duct  of  the  gland 
is  always  patulous  upon  the  surface.  Milium  usually  exists  singly, 
the  skin  looking  normal ;  while  comedo  is  more  general,  the  surface 
having  a  soiled  and  greasy  appearance. 

Prognosis.     Favorable. 

Treatment.  As  a  riile  no  treatment  is  needed,  the  number  being 
few  and  their  presence  of  no  consequence. 

If  their  removal  be  desirable,  two  modes  suggest  themselves:  one, 
to  open  the  cyst  with  a  fine-bladed  bistoury,  and  turning  the  contents 
out,  destroying  the  remaining  sack  by  the  application  of  either  tinctura 
iodi  or  acidum  chromici ;  or,  the  cyst  may  be  destroyed  by  electrolysis. 
If  a  tendency  to  recur  is  shown,  the  plan  may  be  repeated. 

SEBACEOUS  CYST. 

Synonyms.     Wen  ;  sebaceous  tumor  ;  encysted  tumor. 

Definition.  A  distention  of  the  sebaceous  gland  and  duct,  with 
hypertrophy  of  the  walls,  which  forms  a  thick,  tough  sack  or  cyst ; 
characterized  by  the  appearance  of  a  firm  or  soft,  more  or  less  rounded 
tumor,  having  its  seat  in  the  skin  or  subcutaneous  connective  tissue. 

Cause.     Unknown. 

Pathology.  Hypertrophy  of  the  gland  and  duct  walls,  the  result 
of  pressure  from  the  accumulated  contents,  which  consist  of  the  altered 
products  of  the  sebaceous  secretion. 

Symptoms.  The  development  of  wens  is  slow  and  insidious. 
The  localities  where  they  are  more  commonly  developed  are  the  scalp, 
face,  back  and  scrotum. 

The  tumors  occur  singly  or  in  numbers,  in  size  from  a  pea  to  a 
walnut,  or  larger,  in  shape  either  rounded,  flattened  or  semi-globular; 
in  consistency  they  are  either  hard  or  soft,  and  doughy  ;  they  are 
freely  movable  and  painless. 


DISEASES   OF   THE   SKIN.  377 

Diagnosis.  Sebaceous  cysts  may  be  confounded  with  fatty 
tumors. 

Treatment.  Excision  and  careful  and  thorough  dissection  of  the 
cyst. 

HYPERIDROSIS. 

Synonyms.     Hydrosis  ;  ephidrosis  ;  excessive  sweating. 

Definition.  A  functional  disorder  of  the  sweat  glands  ;  charac- 
terized by  an  increased  secretion  of  sweat.  The  sweating  may  be 
either  general  or  partial. 

Causes.  Often  undetermined  ;  occasionally  inherited  ;  nervous 
derangements  ;  malaria  ;  diseases  of  the  heart  and  lungs. 

Pathology.  A  functional  derangement  of  the  sudoriparous 
glands,  over  which  the  vasomotor  system  has  control.  The  char- 
acter of  the  secretion,  chemically,  may  not  differ  from  the  normal. 

Symptoms.  Universal  general  sweating,  such  as  occurs  during 
the  course  of  pneumonia,  rheumatism,  tuberculosis,  typhoid  and  other 
febrile  maladies,  can  hardly  be  considered  a  distinct  affection. 

Hyperidrosis  may  be  acute  or  chronic,  the  amount  slight  or  large, 
being  constant  or  paroxysmal,  the  extent  general  or  local,  and  it  may 
or  may  not  be  symmetrical. 

Bromidrosis  is  the  designation  when  the  secretion  has  an  offensive 
odor. 

Chromidrosis  is  the  designation  when  the  fluid  poured  forth  is  vari- 
ously colored. 

Uridrosis  is  the  designation  when  the  excretion  from  the  sweat 
glands  contains  the  elements  of  the  urine  and  particularly  urea. 

Phosphoridrosis  is  the  designation  when  the  perspiration  appears 
luminous  in  the  dark. 

Local  hyperidrosis  occurs  most  commonly  upon  the  palms,  soles, 
axillae  and  genitalia. 

Hyperidrosis  of  the  palms  may  be  so  profuse  that  the  fluid  accumu- 
lates and  keeps  the  parts  constantly  macerated,  the  wearing  of  gloves 
being  impossible,  for  as  soon  as  the  parts  are  wiped  dry  they  are  again 
bathed  in  the  secretion. 

Hyperidrosis  of  the  soles  is  a  disagreeable  and  often  distressing 
condition,  as  the  socks  and  shoes  become  saturated,  and  thus  keep 
the  soles  constantly  bathed,  allowing  the  macerated  epidermis  to  peel 
off",  leaving  the  more  tender  skin  exposed,  causing  pain  and  distress 


378  PRACTICE   OF   MEDICINE. 

when  walking.  The  maceration  of  the  epidermis,  the  secretion  about 
the  toes,  together  with  the  moisture  of  the  'socks  and  the  soles  of  the 
shoes,  promote  the  rapid  development  oi  X}ci.^  bacteria  fcetidum  ;  all 
these  together  produce  a  most  disagreeable,  disgusting  and  persistent 
odor,  which  is  termed  broinidro sis  pedum. 

Hyperidrosis  of  the  genitalia  attacks  males  more  particularly,  giving 
rise  to  a  disagreeable,  penetrating  odor. 

The  sweating  may  be  limited  to  one  side — U7iilateral  hyperidrosis. 

Prognosis.  The  majority  of  cases  are  extremely  intractable; 
complete  recovery  is  rare  in  a  fair  proportion,  while  some  cases  are 
easily  relieved. 

Treatment.  The  general  condition  of  the  patient  must  receive 
proper  attention. 

Local  treatfnent  is  the  most  valuable,  however,  in  this  alfTection. 

The  parts  should  be  cleansed  and  immediately  dried,  and  then 
dusted  with  some  one  of  the  numerous  dusting  powders.  The  follow- 
ing is  a  valuable  powder  : — 

R.     Acidi  salicylat., gr.  xx 

Zinci  oleat., ^j.  M. 

Perhaps  the  very  best  local  application  is  tinctura  belladonncE,  either 
diluted  or  full  strength. 

In  hyperidrosis  of  the  palms  and  soles,  the  following  are  valuable, 
first  washing  the  parts  with  a  weak  solution  of  acidum  carbolicum  : — 

R  .     Acidi  salicylici, .^ss 

Cretae  ])raep., 5j 

Aluminis  exsic, ^j. 

M.  et  powder  finely. 

SiG. — Apply  to  parts  with  puff  ball. 


Or— 


Or— 


R.     Acid,  salicylici, 3  parts 

Pulv.  amyli 10  parts 

Pulv.  soapstone 87  parts.  M. 

Sic;. — Sift  into  shoes  and  stockings. 


R.     Ungt.  picis  lirjuidoe, 

Ungt.  suiphuris, aa J^'y 

SiG. — Spread  on  cloth  and  applied  with  bandage.     (Wilson.) 


DISEASES   OF  THE  SKIN.  379 

Or— 

R .     Potassii  permanganat., gr.  ij 

Aquae,  destil., f^j.  M. 

A  saturated  solution  of  acidiim  boracicum  applied  frequently  to  the 
hands  and  feet  often  proves  curative. 

For  obstinate  cases,  involving  the  palms  or  soles,  the  following  plan 
of  treatment,  as  suggested  by  Hebra,  will  be  found  of  the  greatest 
service.  It  is  imperative  that  the  various  steps  be  closely  followed : 
"  The  parts  are  to  be  cleansed  with  water  and  soap,  and  the  follow- 
ing ointment  appHed  on  pieces  of  cloth  cut  to  the  size  of  the  region. 
Lint  smeared  with  the  ointment  is  also  to  be  placed  between  the  toes 
or  fingers,  so  that  every  portion  of  the  skin  may  be  covered  with  a 
layer  of  the  ointment. 

R .     Emplast.  diacbyli, , f^Vf 

Olei  olivffi, f  J  iv. 

The  plaster  to  be  melted,  and  the  oil  added  and  stirred  until  a  homo- 
geneous mass  results. 
SiG. — To  be  used  on  cloths. 

"  The  cloths  are  to  be  changed  every  twelve  hours,  when  the  parts 
are  not  to  be  washed,  but  rubbed  with  dry  lint  and  starch  dusting 
powder,  after  which  new  dressings  are  again  to  be  applied  in  the 
same  manner.  This  proceeding  is  to  be  continued  from  one  to  two 
weeks.  When  the  disease  is  upon  the  soles,  the  patient  may  walk 
about  in  loose  shoes."  After  a  week  or  ten  days  the  ointment  can 
be  discontinued,  but  the  dusting  powder  is  to  be  continued  for  a  con- 
siderable period.  If  relapses  occur,  the  original  treatment  should 
again  be  instituted. 

SUDAMINA. 

Synonyms.     Sudamen  ;  miliaria  crystaUina  (Hebra). 

Definition.  A  non-inflammatory  affection  of  the  sweat  glands  ; 
characterized  by  the  rapid  development  of  millet-seed-sized,  translu- 
cent, whitish  vesicles,  in  great  numbers,  upon  any  portion  of  the  body. 

Causes.  A  high  temperature,  causing  unusual  activity  of  the 
sudoriparous  glands. 

Patholog'y.  The  glands  being  excited  beyond  their  capacity  for 
normal  excretion,  the  excessive  fluid,  instead  of  escaping  upon  the 


380  PRACTICE   OF   MEDICINE. 

surface,  from  some  cause  collects  between  the  layers  of  the  epidermis, 
in  the  form  of  minute,  translucent,  pin-point-sized  vesicles. 

Symptoms.  Each  minute  vesicle  is  distinct,  but  they  exist  in 
great  numbers,  very  closely  resembling  drops  of  free  sweat.  They 
develop  rapidly,  never  coalesce,  become  puriform  or  rupture.  Fresh 
crops  form  from  time  to  time.  Their  duration  is  transitory ;  the  fluid 
is  absorbed,  the  covering  of  each  dries,  forming  a  thin,  delicate  mem- 
brane, which  disappears  as  a  slight  desquamation. 

Treatment.  The  treatment  is  that  of  the  disease  with  which 
they  occur. 

ANIDROSIS. 

Definition.  A  functional  disorder  of  the  sweat  glands  ;  charac- 
terized by  a  diminished  or  insufficient  secretion  of  sweat. 

Cause.  The  result  of  a  congenital  deficiency  of  the  sweat 
glandular  apparatus.  Local  anidrosis  may  result  from  injury  to  a 
nerve,  during  the  course  of  chronic  diseases  of  the  skin,  as  ichthyosis, 
eczema,  psoriasis,  lepra  and  elephantiasis  arabum.  In  rare  cases  an 
individual  ceases  to  sweat  entirely  at  times  ;  in  such  cases  the  general 
health  is  impaired,  and  during  the  hot  season  much  suffering  may 
ensue. 

Treatment.  Means  to  promote  the  activity  of  the  skin  and 
glands  is  the  indication,  such  as  the  ingestion  of  large  quantities  of 
water,  hot  baths  and  steam  baths,  friction  and  the  use  of  sudorifics, 
the  most  valuable  of  which  \s  pilocarpus. 

HYPERiEMIAS  OF  THE  SKIN. 

ERYTHEMA  SIMPLEX. 

Definition.  An  acute  affection  of  the  skin,  in  which  occurs  an 
abnormal  quantity  of  blood  in  the  dermal  vessels;  characterized  by 
discoloration,  which  disappears  upon  pressure  and  with  more  or  less 
local  increase  of  temperature. 

Varieties.     Idiopathic  erythema  ;  symptomatic  erythema. 

Causes.  Idiopathic  erythema;  heat,  cold,  pressure,  friction,  or 
the  contact  of  irritants,  such  as  mustard,  arnica  and  dyestuffs. 

Symptomatic  erythema  occurs  most  frequently  in  childhood,  from 
diseases  of  the  stomach  and  intestines;  during  the  course  of  the 
various  exanthemata. 


DISEASES   OF   THE   SKIN.  381 

Symptoms.  A  more  or  less  rapidly  developed  redness  of  the 
skin,  varying  in  color  from  pink  or  light  red  to  dark  red,  which 
disappears  upon  pressure,  to  rapidly  return  again.  The  extent  and 
form  of  the  congestion  varies  according  to  the  cause,  at  times  being 
as  small  as  a  coin  and  isolated,  and  again  diffused  over  a  large 
area.  The  temperature  of  the  congested  part  is  slightly  above  the 
normal. 

Slight  itching  and  burning  are,  usually,  associated  with  the  discol- 
oration. 

Diagnosis.  Erythema  resembles  acute  dermatitis  in  color,  but 
the  subjective  symptoms  of  the  latter  are  so  decided  that  an  error 
should  not  occur. 

Treatment.  Controlled  by  the  cause,  which  should  be  removed, 
and  the  local  application  of  some  one  of  the  various  dusting  powders. 

ERYTHEMA  INTERTRIGO. 

Definition,  An  acute  congestion  of  the  skin  ;  characterized  by 
redness,  heat,  increased  perspiration,  and  an  abraded  surface,  with 
maceration  of  the  epidermis. 

Causes.  In  the  fleshy,  from  contact  or  friction  of  opposing  sur- 
faces exposed  to  warmth — chafing.  In  children  and  infants  contact 
of  moist  clothing;  also  disorders  of  digestion. 

Symptoms.  Parts  where  the  natural  folds  of  the  skin  come  in 
contact  with  one  another,  as  the  nates,  perineum,  groins,  axilla  and 
beneath  the  mammse,  in  the  fleshy  and  in  infants,  become  red,  hot, 
painful,  and  have  an  increased  flow  of  perspiration,  which  in  turn 
softens  the  epidermis,  giving  rise  to  an  acrid  mucoid  fluid.  If  not 
checked  by  the  removal  of  the  cause  and  the  application  of  the  dust- 
ing powders,  inflammation — dermatitis — results. 

Treatment.  The  congested  parts  should  be  thoroughly  washed 
with  water  and  castile  soap,  or  with  bran-water,  and  carefully  dried 
with  a  soft  towel.  The  opposing  folds  of  the  skin  are  to  be  kept  sepa- 
rated with  lint  or  soft  linen,  the  parts  first  covered  with  cretcE  pra- 
parata,  zinci  oxiduni,  bismuthi  subnitras,  amylutn,  lycopodiujn  or 
buckwheat  flour. 


382  PRACTICE   OF   MEDICINE. 

INFLAMMATIONS  OF  THE  SKIN. 
ECZEMA. 

Synonyms.     Tetter  ;  salt  rheum  ;  scall. 

Definition.  A  non-contagious  inflammation  of  the  skin,  charac- 
terized by  any  or  all  of  the  results  of  inflammation  at  once  or  in  suc- 
cession, such  as  erythema,  papules,  vesicles  or  pustules,  accompanied 
by  more  or  less  infiltration  and  itching,  terminating  in  a  serous  dis- 
charge, with  the  formation  of  crusts,  or  in  desquamation. 

Forms.    Aaite ;  chronic. 

Varieties.  Eczema  erythematosnin  ;  eczema  vesiciilosum  ;  eczema 
pustu/os2if?i ;  ec ze?n a  papillosum  ;  eczema  rubrttm  ;  eczema squa77iosMm ; 
eczema  fissum;  eczema  verrucosum  ;  eczema  sclerosum. 

Cause.  Eczema  attacks  persons  in  all  spheres,  the  rich,  the  poor, 
the  infant  or  the  aged,  and  males  or  females.  Many  families,  espe- 
cially those  having  the  "  catarrhal  predisposition  or  peculiarity  of  con- 
stitution," seem  more  liable;  indeed,  it  appears  probable  that  a  pre- 
disposition to  eczema  may  be  transmitted  from  parent  to  child. 
Among  the  causes  suggested  are :  dentition,  improper  food,  gastro- 
intestinal disorders,  intestinal  parasites,  deficient  urinary  secretion,  the 
rheumatic  and  gouty  diathesis,  vaccination,  prolonged  contact  of  hot 
fomentations,  heat  and  cold,  and  contact  with  the  poison  vine  (rhus 
toxicondendron)  and  poison  tree  (rhus  venenata). 

Pathology.  Eczema  is  a  catarrhal  inflammation  of  the  skin — 
a  dermatitis  with  superficial  serous  exudation.  There  is  first  hyper- 
CEmia  or  congestion  of  the  vessels  of  the  skin — eczema  erythematosum 
when  uniformly  distributed,  eczema  papulosum  when  the  congestion 
is  limited  to  distinct  points.  The  hypersemia  is  soon  followed  by  a 
serous  exudation.  If  the  superficial  exudation  be  profuse  enough  to 
form  small  drops,  and  if  the  epidermis  possess  sufficient  resisting 
power  not  to  give  away  immediately  before  it,  vesicles  form,  producing 
the  variety  known  as  eczema  vesiculosum  ;  if  the  vesicles  contain  a 
large  admixture  of  young  cells,  so  that  the  serum  be  turbid,  yellow  and 
purulent,  the  vesicles  become  pustules,  termed  eczema  pustulosum  ; 
if  the  serous  exudation  be  not  sufficient  to  either  elevate  or  break 
through  the  epidermis,  instead  of  either  vesicles  or  pustules  forming 
there  occur  dry  scales,  rising  from  the  reddened  skin — eczema  squa- 
mosum. When  the  exudation  is  sufficient  to  detach  the  epidermis, 
thus  exposing  the  red  and  moist  corium,  it  is  termed  eczema  rubrum. 


DISEASES   OF   THE   SKIN.  383 

In  chronic  eczema  the  skin  is  sub-acutely  inflamed ;  is  very  much 
thickened,  hardened  and  infiltrated  with  cells  which  extend  through- 
out the  entire  corium,  even  into  the  subcutaneous  connective  tissue. 
The  papillae  are  enlarged  and  at  times  may  be  distinguished  with  the 
naked  eye.  Pigmentation  may  take  place  in  the  deep  layers  of  the 
rete,  and  in  the  corium,  especially  about  the  vessels. 

Symptoms.  Eczema  is  the  most  common  of  all  cutaneous  affec- 
tions, with  symptoms  varying  in  accordance  with  the  particular  va- 
riety of  the  affection  and  its  location,  although  the  general  character- 
istics of  a  catarrhal  inflammation  are  present  in  all ;  these  are  redness ^ 
either  limited  or  diffused,  heat  of  the  part  affected,  swelling,  the  result 
of  the  serous  exudation,  giving  rise  either  to  a  discharge  (weeping), 
with  subsequent  crusting,  or  to  the  deposition  of  plastic  material. 
The  most  constant,  annoying  and  troublesome  symptom  is  the  itching, 
or  at  times  burning,  which  varies  from  that  which  is  simply  annoying 
to  that  which  is  almost  unendurable. 

Eczema  runs  its  course  either  as  an  acute  affection,  lasting  a  few 
weeks,  not  to  return,  or  to  return  acutely  at  wide  intervals,  or,  as  is 
much  more  frequently  the  case,  it  assumes  a  chronic  state,  continuing 
with  more  or  less  variations  for  months,  years  or  even  a  lifetime.  It 
may  appear  upon  any  portion  of  the  body,  or  involve  the  whole 
integument  {eczema  universale).  The  varieties  are  named  in  the 
order  which  the  lesions  assume  at  its  commencement. 

Eczema  Erythematosum.  An  erythema  or  redness  of  the 
surface,  with  a  yellow  tinge.  The  size  of  the  macule  may  be  very 
small  or  quite  extensive,  with  irregular  outlines.  There  may  be  slight 
swelling  of  the  patch,  but  no  discharge  occurs  unless  it  be  where  two 
surfaces  come  into  contact  {eczema  intertrigo),  as  about  the  genitalia. 
Cases  without  discharge  are  covered  after  a  few  days  with  a  thin  film 
of  dry,  exfoliating  epidermis  or  scale  {eczema  squamosu7n).  When  a 
discharge  (weeping)  or  moisture  occurs,  it  is  followed  with  more  or 
less  crusting. 

Intense  itching  is  a  constant  symptom. 

Eczem.a  Vesiculosum.  Begins  with  burning,  paiti,  redness  and 
swelling,  followed  by  an  immense  number  of  minute  vesicles,  either 
discrete  or  confluent,  rapidly  distending  with  a  clear  or  yellowish 
fluid  and  attended  with  intense  itching.  Soon  the  vesicles  rupture, 
the  fluid  rapidly  diffusing  over  the  surface  and  drying  into  yellowish, 
honey-like  crusts.    New  crops  of  vesicles  soon  follow,  or  if  subsequent 


384  PRACTICE   OF   MEDICINE. 

vesication  do  not  occur,  the  fluid  rapidly  diffuses  over  the  excoriated 
surface,  which  also,  in  turn,  dries  into  large,  yellowish  crusts.  After 
a  variable  time  the  various  symptoms  gradually  subside. 

Itching  \s  the  most  prominent  subjective  symptom,  is  iatense,  and 
eives  rise  to  an  irresistible  desire  to  scratch. 

All  portions  of  the  body  are  liable  to  this  variety  of  eczema,  the 
most  frequent  location,  however,  being  the  face,  and  when  occurring 
in  children  is  commonly  known  as  crusta  lactea. 

Eczema  Pustulosura,  or  Eczema  Impetiginosum.  This 
variety  usually  begins  as  vesicular  eczema,  the  fluid  rapidly  changing 
to  pus.  After  a  short  period,  during  which  the  pustules  have  in- 
creased in  size,  they  burst  and  the  escaped  fluid  forms  thick,  greenish- 
yellow  crusts,  which,  in  turn,  rapidly  dry  and  fall  off,  or  crumble 
away. 

The  location  of  this  variety  is  most  usually  upon  the  scalp  and  face. 
It  is  stubborn  to  treatment.     Itching  \%  a  prominent  symptom. 

Eczema  Papulosum,  or  Lichen  Simplex.  This  variety  of 
eczema  appears  in  the  form  of  small,  rounded  papules,  the  size  of  a 
pin-head,  of  bright  red,  or  at  times  dark  red  color ;  they  may  be  either 
discrete  or  confluent.  In  some  cases  all,  while  in  others  a  greater  or 
less  number  of  the  papules  pass  into  vesicles  and  run  much  the  same 
course  as  vesicular  eczema.  The  itching  is  of  the  most  intense  char- 
acter, leading  to  severe  scratching,  by  which  the  summits  of  the 
papules  are  torn,  causing  them  to  bleed,  the  blood  forming  dark  red 
crusts. 

Eczema  Rubrum,  or  Eczema  Madidans.  This  is  a  variety 
only  from  a  clinical  standpoint.  It  may  result  from  any  of  the  fore- 
going varieties.  The  surface  of  the  skin  is  inflamed  and  infiltrated, 
red,  moist  and  weeping,  the  profuse  serum  rapidly  drying  into  thick, 
yellowish,  greenish  or  brownish  crusts,  the  color  depending  upon  the 
character  of  the  fluid,  which  may  be  serum,  pus  or  blood  from  the 
exposed  and  lacerated  corium.  The  crusts  adhere  closely  and  firmly 
to  the  part,  and,  unless  removed  by  mechanical  means,  may  remain 
indefinitely,  the  disease  pursuing  its  course  beneath. 

Eczetna  rubrum,  or  niadidajis,  "then,  presents  two  appearances — 
as  it  occurs  with  its  crust,  and  as  it  exists  without  this  covering.  In 
the  one  case  the  skin  itself  is  altogether  obscured  l)y  a  dirty,  yellowish 
or  brownish  crust ;  in  the  other  the  skin  presents  a  bright  or  violaceous 
red.  punctate,  wounded  surface,  deprived  in  great  part  of  its  epider- 


DISEASES   OF   THE   SKIN.  385 

mis,  and  exuding  a  scanty  or  profuse,  clear  or  opaque,  syrupy,  yel- 
lowisli  fluid.  Sometimes  tliis  is  streaked  with  blood."  The  itching 
and  burning  are  severe.  It  may  develop  upon  any  portion  of  the 
body,  but  is  most  commonly  seen  upon  the  legs,  particularly  in  elderly 
people.     Its  course  is  chronic  and  increasing  in  severity. 

Eczeraa  Squamosura.  This  is  also  a  clinical  variety.  It  results 
from  the  erythematous,  vesicular,  pustular  or  papular  varieties  of  the 
affection,  but  more  particularly  the  first  named.  A  typical  case  pre- 
sents itself  in  the  form  of  variously  sized  and  shaped  reddish  patches, 
which  are  dry,  or  more  or  less  scaly,  the  skin  being  more  or  less  infil- 
trated or  thickened.     Its  course  is  usually  chronic. 

Eczema  Pissum,  or  Riraosum.  Another  clinical  variety. 
During  the  progress  of  the  erythematous,  vesicular  or  pustular  varieties 
of  eczema,  cracks  ox  fissures  result  when  the  lesion  occurs  upon  regions 
subject  to  constant  motion,  such  as  between  the  fingers,  toes  and  the 
various  joints.  At  times  the  fissures  are  extensive  and  deep,  and  of 
a  bright  red  color,  showing  the  true  skin,  and  intensely  painful  upon 
motion.     Chapped  hands  are  typical  instances  of  fissured  eczema. 

Eczema  Sclerosum..  This  variety  of  eczema,  occurring  most 
commonly  on  the  palms,  soles  and  finger-tips,  is  characterized  by  hy- 
pertrophy of  the  papillae,  showing  itself  as  hard,  thickened,  infiltrated, 
localized  patches,  which  are  most  apt  to  crack  (eczema  fissum). 

Eczema  Verrucosum,  or  Papillomatosum,  differs  from  the 
foregoing  in  that  the  thickened,  infiltrated  patch  has  a  warty  verru- 
cous appearance.     Its  course  is  chronic. 

Eczema  Acutumi  et  chronicura.  The  line  which  divides 
these  two  conditions  is  drawn  by  means  of  the  clinical  and  patho- 
logical features.  The  course  of  eczema,  in  the  majority  of  instances, 
is  chronic.  It  may  be  said  that  so  long  as  the  general  inflammatory 
symptoms  are  high  and  the  secondary  changes  slight,  the  affecdon  is 
acute,  and  that  when  the  process  has  settled  itself  into  a  definite  line 
of  action,  continually  repeating  itself  and  accompanied  by  secondary 
changes,  it  is  chronic. 

Diag'nosis.  The  many  varieties  in  which  eczema  manifests  itself 
renders  the  diagnosis  a  matter  of  importance.  The  following  charac- 
teristic features  of  eczema  are  of  value  in  arriving  at  a  diagnosis : 
infiamination,  sxvelling  and  cedeina,  thickening  from  cell  infiltration, 
redness,  the  discharge  or  moisture,  followed  by  crustifig,  on  removal 
of  which  a  moist  surface  is  presented,  and  itching  and  burning. 
32 


386  PRACTICE   OF   MEDICINE. 

Erysipelas  may  be  confounded  with  erythematous  or  vesicular 
eczema.  The  points  of  difference  are  the  fever  and  other  general 
disturbances,  the  deep-seated  inflammation  of  the  skin,  rapidly- 
spreading,  with  heat,  swelling  and  oedema  without  moisture,  giving 
the  surface  a  deep  red,  shining  and  tense  appearance,  are  character- 
istic of  erysipelas  and  very  different  from  eczema. 

Herpes  and  vesicular  eczema  bear  some  resemblance  to  each  other; 
herpes  zoster  is  distinguished  by  the  neuralgic  pains  which  are  asso- 
ciated with  it  and  are  never  associated  with  eczema.  The  other  varie- 
ties of  herpes  occurring  about  the  face  and  genitalia  run  their  course 
in  a  few  days,  while  eczema  is  of  much  longer  duration  and  has  a 
discharge  followed  by  crusting. 

Seborrhcea  of  the  scalp  and  squamous  eczema  of  the  same  region 
closely  resemble  each  other.  In  eczema,  however,  the  skin  is  more 
or  less  red,  inflamed  and  thickened,  and  the  scales  larger,  less  abun- 
dant and  less  greasy  and  drier  than  seborrhcea.  In  eczema  the  scales 
are  usually  seated  upon  a  circumscribed  patch,  while  in  seborrhcea,  as 
a  rule,  they  cover  the  scalp  uniformly.  Itching  occurs  with  both  dis- 
orders. The  history  of  the  two  affections  should  be  of  material  aid 
to  render  the  diagnosis  clear ;  still,  however,  in  many  cases  the  diffi- 
culty is  marked.     Both  are  frequent  affections. 

Psoriasis  should  never  be  confounded  with  a  typical  case  of  eczema, 
but  chronic  eczema,  with  infiltrated,  inflammatory,  scaly  patches,  fre- 
quently looks  very  much  like  psoriasis. 

Treatment.  There  is  no  specific.  The  indications  are  for  the 
removal  of  the  cause,  where  it  can  be  ascertained,  if  it  be  possible, 
and  attention  to  the  general  health.  The  diet  should  be  of  the  most 
nutritious,  but  easily  digestible  character  ;  fresh  air  and  moderate 
exercise  are  also  essential  elements  in  the  treatment,  together  with 
attention  to  the  secretions.  If  the  bowels  be  sluggish,  much  benefit 
follows  the  use  of  such  laxative  mineral  spring  waters  as  the  Hathorn, 
or  Hunyadi  Arpad,  or  a  morning  dose  of  iJiagnesii  sulphas.  For  chil- 
dren, syrupus  rhei,  to  which  may  be  added  magnesia  ;  or  what  is  per- 
haps more  efficient,  a  small  dose  of  hydrargyri  chloridimi  mite.  If 
the  urinary  secretion  be  small  and  the  urine  heavy,  use  should  be 
made  of  full  doses  of  poiassii  acetas  and  large  draughts  of  water.  If 
either  a  rheumatic  or  gouty  disposition  exist,  lithium  salts,  to  which 
may  be  added  vinuin  colchici  seminis.  If  a  scrofulous  tendency 
exist,   use  oleum  morrhuce   and  syrupus  ferri  iodidi.      If  anaemia, 


DISEASES   OF  THE  SKIN.  387 

ferriim,  quinina,  strychnina  and  the  mineral  acids,  or  syrupus  hypo- 
phosphitis  comp.,  are  indicated. 

Locally :  the  most  important  means  of  treatment  for  all  the  varie- 
ties of  eczema  are  with  local  remedies,  suiting  the  appropriate  ones 
for  each  particular  case,  as  no  one  combination  is  applicable  for  all 
varieties.  It  maybe  stated,  as  a  principle,  that  nothing  irritant  is  ever 
to  be  applied  to  the  surface  in  acute  eczema,  and  that  in  the  chronic 
form  nothing  can  hardly  be  too  stimulating.  The  too  frequent  wash- 
ing or  general  baths  are  to  be  avoided,  as  they  have  a  tendency  to 
macerate  the  already  softened  epidermis.  For  cleansing  purposes,  in 
the  majority  of  instances,  ordinary  Castile  soap  is  sufficient. 

Crusts  and  scales  are  nearly  always  present  in  eczema,  and  are  to 
be  removed  before  medicaments  can  be  successfully  applied.  Their 
removal  is  to  be  secured  by  saturation  with  oily  preparations,  a  starch 
or  other  mild  poultice,  or  a  saturated  solution  of  acidum.  boracicum. 
After  their  removal  the  parts  are  to  be  cleansed  with  Castile  soap  and 
water. 

For  acute  erythematous  or  vesicular  eczema,  use  but  little,  or  what 
is  better,  no  soap  or  water  ;  instead,  cover  the  parts  with  a  dusting 
powder,  such  as — 

R.     Pulv.  camphorae, ^j 

Zinci  oleat., ^\] 

Pulv.  amyii., J  j.  M. 

SiG. — Dusting  powder. 

For  acute  vesicular  eczona,  Dr.  J.  C.  White  recommends  bathing 
the  affected  part  with  lotio  nigra  (hydrargyri  chlor.  mite  gr.  viij, 
liquor  calcis  f^j),  full  strength,  or  diluted  with  equal  parts  of  lime 
water,  apphed  by  means  of  a  sponge  or  a  piece  of  cloth,  for  ten  or 
fifteen  minutes  at  a  time,  and  at  intervals  of  a  few  hours  or  longer, 
the  sediment  being  allowed  to  remain  on  the  skin  ;  after  which  tmg. 
zinci  oxid.  is  to  be  gendy  rubbed  over  the  part.  As  a  rule,  the  itching 
and  burning  are  relieved  at  once,  and  the  affection  often  arrested. 
Good  results  follow  the  use  of  a  saturated  solution  of  acidum  bora- 
cicu7n. 

There  are  cases  which  do  better  from  the  application  of  ointments, 
of  which  the  following  is  valuable  : — 

R  •     Zinci  oleat., 

Olei  olivae, aa  .....     ;^iv.  ]VI. 


388  PRACTICE   OF   MEDICINE. 

Or,  bismuth  oleaie,  made  according  to  the  following  formula  of  Dr. 
McCall  Anderson  : — 

R.     Bismuthi  oxidi, .^j 

Acidi  oleici, ^j 

Cerre  albse, ,^iij 

Vaselini, 3;ix 

01.  rosae, TT\^ij.  M. 

If  the  discharge  be  excessive,  the  following  formula  of  Prof.  Bar- 
tholow  I  have  seen  useful : — 

R.     Plumbi  acetat, ^ss 

Pulv.  camphorse, J^r-  xv 

01.  amygdal., f^ij 

Cerat.  flav., ^j.  M. 

The  late  Dr.  Frank  Maury  was  partial  to  the  following  formula  in 
vesicular  eczema : — 

R.     Hydrargyri  chlor,  mite, gr.  xx 

Ung.  zinci  oxid.  benz., ^j.  M. 

For  eczema  papulosum  the  following  lotions  are  particularly 
valuable : — 

R.     Acid,  carbolici, 3J-ij 

Glycerini, f^iv 

Alcoholis, f^iv-vj 

Aquse  destil, ad Oj.  M. 

— DUHRING. 

Or— 

R.     Thymol, gr.  x-xx 

Alcoholis, f  5j 

Aquae  destil i%\.  M. 

After  the  disappearance  of  the  more  acute  symptoms,  more  stimu- 
lating applications  are  indicated,  among  which  are  acidum  carboli- 
cum,  thymol,  pix  liquida  or  oleum  cadimim.  It  is  to  be  remembered, 
however,  that  the  more  chronic  the  affection  and  the  less  the  inflam- 
matory symptoms,  the  more  successful  is  tar  in  the  treatment  of 
eczema. 

Dr.  Duhring  considers  the  following  one  of  the  most  elegant  of  the 
tarry  ointments : — 


DISEASES   OF  THE  SKIN.  389 

R.     Olei  cadini, f.^iss 

Cerati  simplicis, Jj 

01.  amygdal  amar., gtt.  x.         M. 

Ft.  ungt. 

Or— 

R.     Picis  liquidae, fgj 

Glycerini, f^] 

Alcoholis, f^vj 

01.  amygdal.  amar., gtt,  xv,       M. 

SiG. — To  be  rubbed  firmly  into  the  skin. 

The  following  is  Dr.  Bulkley's  valuable  "liquor  picis  alkalinus  :  "— 

R.     Picis  liquidse, f^ij 

Potassae  causticse, 5J 

Aquae  destillatae, f  3  v-  M. 

The  potassa  to  be  dissolved  in  water  and  gradually  added  to  the  tar 
with  rubbing  in  a  mortar. 

SiG. — To  be  used  diluted. 

A  very  elegant  preparation  of  tar  is  the  French  mixture  known  as 
"  Goudron  de  Guyot." 

For  eczema  rubrmn,  one  of  the  most  intractable  varieties  of  the 
disease,  especially  the  chronic  eczema  of  the  legs,  the  following 
mode  of  treatment,  first  suggested  by  Hebra,  is  the  treatment  par 
excellence. 

The  accompanying  instructions  are  to  be  adhered  to.  A  lump  of 
the  sapo  viridis  (made  originally  of  herring  fat  and  potassa,  and  con- 
taining three  per  cent,  of  caustic  potassa),  the  size  of  a  small  nut,  is 
smeared  upon  a  piece  of  wet  flannel  and  applied  to  the  affected  part, 
and  firmly  rubbed  until  the  soap  has  disappeared,  when  the  flannel  is 
to  be  dipped  into  warm  water  and  again  applied  to  the  part  and 
rubbed  until  an  abundant  lather  forms,  more  water  being  added 
from  time  to  time  until  the  suds  are  most  abundant,  when  the  surface 
is  thoroughly  washed  and  freed  from  all  the  soap  and  carefully  dried, 
after  which  the  following  (Hebra's  diachylon)  ointment,  having  been 
spread  before  the  application  of  the  soap,  is  to  be  applied.  It  is  pre- 
pared as  follows : — 

"  Fifteen  ounces  of  the  best  olive  oil  are  added  to  two  pounds  of 
water,  and  heated  to  boiling  in  the  water  bath.  Three  ounces  and 
six  drachms  of  an  equally  good  article  of  litharge  (plumbi  oxidum) 
are   dusted  over  the  fluid  in  ebullition,  which  is  constantly  stirred 


390  PRACTICE   OF   MEDICINE. 

throughout,  in  order  to  prevent  the  formation  of  fatty  acids.  During 
the  cooking,  water  is  occasionally  added  as  required.  The  stirring  is 
to  be  continued  until  the  ointment  is  quite  cold." 

The  ointment  is  spread  upon  strips  of  soft  muslin  and  the  affected 
part  enveloped,  care  being  exercised  that  neither  folds  nor  wrinkles 
occur,  the  whole  being  covered  by  a  firm  roller  and  the  patient  being 
able  to  go  about  as  usual.  The  entire  operation  is  to  be  repeated 
twice  daily. 

A  modification  of  the  above  ointment,  technically  known  as 
"  unguentum  diachyli  albi  of  Hebra,''  has  been  successful  in  my 
hands  in  a  number  of  cases.     The  formula  is  : — 

H .     Eraplast.  plumbi, 

Vaseline, aa ^j 

01.  lavandulse, q.  s.  M. 

Dissolve  with  heat  and  stir  till  cold. 

SiG. — Apply  on  strips,  etc. 

Prof.  Da  Costa  has  used  with  success  in  eczema  rubra,  liquor 
arsenici  et  hydrargyri  iodidi,  TT\,ij-v,  t.  d.,  and — 

R.     Ung.  plumbi  subacet., ^iv 

Acid,  carbolici  cryst., gr-  "j 

Ungt.  petrolei, ^iv.  M. 

SiG. — Apply  freely  on  muslin  strips. 

An  excellent  formula  in  eczema  vulva  is : — 

R.     lodoformi, ^ss 

Bal.  peru., '7^\ 

Vaseline, f,^j.  M. 

SiG. — Apply  on  soft  cloths. 

Eczema  capitis  is  either  erythematous,  vesicular  or  pustular  in 
character.  If  the  first  named,  it  at  once  tends  to  become  chronic, 
settling  into  the  variety  known  as  eczema  squamosum,  often  involving 
the  entire  scalp  and  accompanied  with  intense  itching.  The  pustular 
variety  is  the  more  common  form,  occurring  upon  the  scalp  of  chil- 
dren and  young  adults,  existing  as  a  few  patches,  or,  what  is  more 
frequent,  involving  the  entire  scalp.  The  pustules  soon  rupture,  the 
liquid  drying  into  greenish-yellow  crusts,  which,  if  the  affection  be 
extensive,  cover  the  whole  scalp  with  a  cap  of  crust.  The  hair  be- 
comes matted  and  caked,  the  sebaceous  secretion  collects,  and  if  the 
part  be  not  cleansed  the  head  becomes  offensive.     In  severe  cases  of 


DISEASES   OF   THE   SKIN.  391 

pustular  eczema  of  the  scalp,  enlargement  of  the  lymphatic  glands  of 
the  back  of  the  neck  and  of  those  behind  the  ear  occur ;  they  never 
suppurate.  Pediculi  are  frequently  associated  with  eczema  capitis  of 
children,  either  as  a  primary  cause  or  a  result  of  the  matted  condition 
of  the  hair  constituting  a  favorable  habitat  for  them.  When  present 
they  call  for  active  treatment. 

Eczema  capitis  may  be  confounded  with  psoriasis,  seborrhoea, 
syphihs,  tinea  favosa,  and  tinea  tonsurans. 

Treatment.  If  the  pustular  variety,  removal  of  the  crusts  is  the 
first  indication.  This  is  accomplished  by  saturating  the  scalp  either 
with  oleum  oHvce  or  oleum  amygdalcs  dulcis,  and  then  washing  with 
warm  water  and  soap,  or  the  use  of  a  starch  poultice ;  after  their 
removal  the  application  of  the  following  ointment,  used  by  Prof. 
Da  Costa : — 

R.     Hydrargyri  chlor.  mite., gr.  xx 

Acid,  carbol.  cryst., gT-  "j 

Ung.  petrolei, ^j.  M. 

SiG. — Thoroughly  applied. 

The  late  Prof.  Ellerslie  Wallace  was  fond  of  the  following  : — 

R.     Sodii  carb., gr,  xxx 

Ung.  petrolei, ^j,  M. 

SiG. — Apply  thoroughly  after  removal  of  the  crusts. 

I  have  usually  been  successful  with  cleanliness,  proper  dietary,  the 
internal  use  of  liquor  arsenici  et  hydrargyri  iodidi,  TTLss-j,  well 
diluted,  after  meals,  and  the  local  use  of  unguentum  picis  liquidce 
diluted  with  vaseline. 

In  cases  associated  With,  pediculi,  I  have  succeeded  with  the  follow- 
ing, after  removal  of  the  crusts  : — 

R .     Hydrargyri  ammoniat., gr.  x-xx 

Adeps  benzoat., 5j.  M. 

SiG. — Thoroughly  applied. 

For  the  squamous  variety  of  the  scalp,  the  following  formula, 
recommended  by  Dr.  Duhring,  is  excellent : — 

B  .     Picis  liquidae, f  ^  j 

Glycerini, f^j 

AlcohoHs, f^vj 

01.  amygdalae  amar., gtt.  xv.  M. 

SiG. — Diluted  or  full  strength,  rubbed  thoroughly  into  scalp. 


392  PRACTICE   OF   MEDICINE. 

-  Eczema  faciei.  In  this  location  the  affection  may  be  either  acute 
or  chronic.  In  adults  the  erythematous  variety  is  frequently  encoun- 
tered in  patches  about  the  forehead  and  cheeks.  Eczema  of  the  face 
is  more  common  in  children,  however,  the  varieties  being  the  vesicu- 
lar and  pustular.  It  is  seen  on  the  forehead,  nose  and  upper  lip,  and 
is  associated  with  severe  itching. 

Treatment.     The  same  as  eczema  capitis,  or  the  following : — 

R .     Zinc  oleat., ^\ 

Ung.  petrolei, ^j.  M. 

Eczema  labiormn.  Eczema  attacks  the  lips,  either  alone  or  in  con- 
nection with  other  parts  of  the  face.  One  or  both  lips  may  be  affected. 
The  symptoms  are  :  swelling,  redness,  heat,  infiltration,  slight  scali- 
ness  and  fissures.  The  affection  may  be  in  the  skin  around  the  border 
of  the  mouth,  or  the  vermilion  and  mucous  membrane  of  the  lips. 
The  mouth  may  be  contracted  and  the  lips  partly  glued  together  by 
the  exudation  and  crusts. 

Eczema  labiorum  may  be  confounded  with  herpes  labialis  and 
syphilis. 

Treatment.  Very  difficult  and  discomforting  to  the  patient.  Among 
the  remedies  at  times  successful  are  :  ar genii  nitras,  potassa  nitras, 
acidujn  carbolicum,  pix  liquida,  oleicm,  ergota  and  collodium,fiexile. 

Eczema  palpebrariwi.  A  frequent  occurrence  in  scrofulous  chil- 
dren, showing  itself  along  the  edges  of  the  eyelids.  Pustules  involve 
the  hair  foUicles,  followed  by  the  usual  crusting.  The  symptoms  are 
swelling,  redness  and  itching,  and  unless  the  parts  are  frequently 
cleansed,  the  lids  tend  to  glue  together.  Conjunctivitis  frequently 
complicates  the  affection. 

Treatment.  In  mild  cases  success  follows  the  use  of  zinci  oleat.  or 
glyceritum  acidi  tannici.  In  severe  cases  the  plan  recommended  by 
McCall  Anderson  should  be  pursued.  It  consists  in  the  extraction  of 
the  eyelashes  and  touching  the  edges  of  the  lids  with  a  solution  of 
potassa  in  water,  ten  grains  to  the  ounce.  The  edges  should  be  care- 
fully dried  and  the  lid  everted,  a  very  small  quantity  on  a  delicate 
brush  being  applied,  immediately  neutralizing  the  alkali  with  acidum 
aceticum  or  vinegar. 

Eczema  barbce.  Eczema  of  the  beard  is  characterized  by  the  forma- 
tion of  extensive  pustules,  with  preference  for  about  the  hairs,  drying 
as  yellowish  or  greenish  crusts,  matting  the  hairs  together  and  adher- 


DISEASES   OF  THE   SKIN.  393 

ing  to  the  parts.  The  affection  may  be  confined  to  the  hairy  portions 
ot  the  face,  or  extend  to  other  regions  of  the  face,  be  locahzed  or  gen- 
eral, acute  or  chronic. 

Eczema  barbae  in  general  features  somewhat  resembles  both  tinea 
sycosis  and  sycosis  non-parasitica,  but  sycosis  is  an  inflammation  of 
the  hair  follicles  only  and  is  rarely  associated  with  crusting,  while 
crusting  is  abundant  in  eczema. 

Treatment.  Must  be  energetic  and  decided.  The  crusts  are  to  be 
removed  by  poultice  or  warm  water  and  soap.  Then  the  part  is  to  be 
cautiously  shaved  ;  although  quite  painful  the  first  time,  it  is  hardly  so 
afterward,  as  it  is  to  be  repeated  every  two  or  three  days.  After  shav- 
ing, if  the  attack  be  acute,  the  same  plan  of  medication  as  recom- 
mended by  Hebra  for  eczema  rubrum  is  to  be  practiced,  the  application 
to  be  continuous  both  day  and  night,  or  only  at  night.  If  the  attack 
be  chronic,  the  following  ointment  should  be  applied  after  cleansing 
and  shaving  the  beard  : — 

R.     Hydrargyri  ammoniat.,  .    .    , gr.  xv-xxx 

Sulphur, 3^^~j 

Ung.  petrolei,     .............  3J.  M. 

SiG. — To  be  thoroughly  applied. 

In  this  variety  of  eczema  I  have  seen  marked  benefit  from  the  use 
of  liquor  arsenici  et  hydrargyri  ijdidi,  ni,ij-v,  three  or  four  times 
daily. 

Eczema  auriutn.  Eczema  of  the  ears  may  be  either  erythematous, 
vesicular  or  pustular.  If  the  former,  thickening  results,  with  desqua- 
mation of  flakes  or  large  scales  ;  if  either  of  the  latter,  crusts  form, 
which  may  envelop  the  whole  ear,  the  symptoms  being  swelling,  red- 
ness and  severe  burning  and  itching,  and  if  the  process  extend  into 
the  meatus,  occlusion  may  result,  causing  temporary  deafness.  The 
most  characteristic  symptoms  of  erythematous  eczema  of  the  external 
auditory  canal,  besides  the  appearance  of  small  flakes,  is  intense  and 
persistent  itching. 

Treatment.  For  acute  vesicular  or  pustular  eczema,  removal  of  the 
crusts  and  the  use  of  hydrargyri  chloridi  mite  as  an  ointment  of  the 
strength  of  thirty  grains  to  the  ounce.  If  chronic,  the  use  of  pix 
liquida,  as  already  suggested.  For  chronic  erythematous  eczema  of 
the  external  auditory  canal,  the  following  formula  has  generally  con- 
trolled this  stubborn  condition  : — 
33 


394  PRACTICE   OF   MEDICINE. 

R .     Hy('rargyri  flav.  oxid  , gr.  j-iij 

Morphinne  sulph., .    gr.  j 

Vaseline, ^ij.  M. 

SiG. — Apply  to  the  canal. 

Eczema  genitalium.  This  is  a  most  distressing  condition.  In  the 
male  the-scrotum  and  penis  are  involved  alone  or  together,  the  former 
alone  being  the  more  common,  and  is  complicated  with  eczema  of 
the  inner  side  of  the  thigh  or  thighs.  The  symptoms  of  eczema  of 
the  scrotum  are,  swelling,  often  oedema  as  well,  moisture,  crusts,  and 
painful  fissures,  followed  by  extensive  thickening  and  accompanied 
by  intense  itching.  In  the  female  the  affection  attacks  the  labiae,  and, 
rarely,  the  vagina  and  mons  veneris,  and  may  extend  to  the  surround- 
ing parts,  especially  to  the  perineum.  The  symptoms  of  eczema  of 
the  labia  are,  great  swelling,  oedema,  redness,  with  great  heat  and  a 
free  discharge,  forming  crusts,  which  are  apt  to  glue  the  opposing 
surfaces  together.  If  the  variety  be  the  erythematous,  in  place  of  a 
discharge  with  crusts,  the  symptoms  named  are  followed  by  slight 
scales.     The  twitching  is  most  violent  and  distressing. 

Treat7ne7it.  The  parts  attacked  should  be  kept  constantly  envel- 
oped in  cloths  wet  with  a  saturated  solution  of  acidiim  boracicum  until 
the  more  pronounced  inflammatory  symptoms  subside,  when  should 
be  applied  ointments  of  zinci  oleat.  or  hydrargyri  chloridum  mite. 
Persistent  cases  will  often  succumb  to  the  plan  of  treatment  suggested 
by  Hebra  for  eczema  rubrum. 

Eczejna  ani.  The  anus  may  be  attacked  alone  or  associated  with 
eczema  of  the  perineum  and  genitalia.  The  symptoms  are  :  redness, 
swelling,  infiltration  and  thickening,  with  or  without  fluid  exudation. 
Fissures  of  the  anus  are  usually  present,  and  add  to  the  distress  of 
the  patient  the  pain  attending  each  stool.  Persistent  itching  and 
burning,  worse  after  retiring,  adds  to  the  misery  of  the  patient. 

Pruritus  ani  may  be  mistaken  for  eczema  ani.  In  the  former  the 
itching  is  only  associated  with  such  symptoms  of  inflammation  as 
result  from  the  irritation  of  scratching,  while  in  the  latter  inflammatory 
symptoms  precede  the  itching. 

Treatment.  The  more  acute  symptoms  are  relieved  by  bathing 
the  parts  with  a  solution  of  acidum  boracicu?n,  after  which  a  weak 
application  of  acidum.  carbolictim^  either  as  a  lotion  or  ointment. 
The  late  Prof,  S.  D.  Gross  recommended  the  application  of  the 
following : — 


DISEASES   OF   THE   SKIN.  395 

R.     Zinci  oxidi, 3  vj 

Hydrargyri  chlor.  corrosiv., gr.  j 

Glycerini, 3  ij.  M. 

SiG. — Apply  thoroughly  to  affected  parts. 

Eczema  intertrigo.  Parts  of  the  body  that  naturally  come  into  con- 
tact with  each  other,  as  about  the  joints,  the  inner  surfaces  of  the 
nates,  in  the  groins  and  beneath  the  mammae,  are  frequently  attacked 
with  erythematous  eczema,  which  is  frequently,  but  erroneously, 
termed  erythema  intertrigo  or  chafing.  The  symptoms  are  :  redness, 
heat,  and  a  moist,  macerated  surface,  aggravated  by  movement  of 
the  affected  parts. 

Treatment.  The  application  of  a  solution  of  acidum  boracicum, 
or  the  use  of  dusting  powders,  such  as  zinci  oleat.,  aiJiylum  ox  hydrar- 
gyri chloridtim  mite.  It  is  essential  for  successful  treatment  that  the 
opposing  surfaces  be  separated  by  means  of  lint  or  cloths. 

Eczema  manimariim.  The  nipples,  and  more  particularly  those  of 
primiparse,  are  at  times  the  seat  of  a  vesicular  eczema,  with  the  form- 
ation of  crusts  and  fissures,  and  unless  speedily  reheved  develops 
eczema  rubrum.  The  pain  on  nursing  becomes  so  severe  that  the 
mother  is  compelled  to  refuse  the  child.  It  must  be  borne  in  mind 
that  eczema  mammarum  occurs  in  women  who  are  not  nursing  and 
in  single  women. 

Treatnient.     Dr.  Tilbury  Fox  advises  the  following  plan  : — 

"  I.  Great  cleanliness  and  care  in  washing  away  any  remnants  of 
milk  after  each  time  that  the  child  is  put  to  the  breast ;  and,  if  the 
nipple  be  tender  and  excoriated,  use — 

"  2.  A  little  liquor  plumbi  and  calamine  powder,  as  follows  : — 

]^  .     Liq.  plumbi, f^iss 

Pulv,  calaminse  praep., ^iss 

Glycerini, ^j 

Adipis, ad 5J.  M. 

"3.  I  cover  over  the  nipple  with  a  lead  nipple  shield.  This  ex- 
cludes the  air,  keeps  the  part  from  being  chafed,  and  I  think  the 
lead  does  good  after  the  part  has  become  less  red  and  sore.  I  often 
use  a  little  glyceral  tannin,  painted  on  night  and  morning. 

"  The  above  application  can  always  be  removed  with  a  little  cold 
cream  and  a  little  warm  water  sponging  before  the  child  goes  to  the 
breast." 


396  PRACTICE   OF   MEDICINE. 

Eczema  palmanim  et plantarum.  The  features  of  the  affection  in 
both  these  regions  are  identical.  The  diagnosis  is  often  obscured  by 
the  thickened  state  of  the  epidermis.  The  symptoms  are  :  infiltration, 
thickening,  callosity,  moisture  followed  by  dryness,  and  Assuring,  the 
last  named  frequently  becoming  so  deep  and  painful  that  the  patient 
is  unable  to  use  his  hands,  or,  if  on  the  soles,  to  walk. 

The  affection  is  almost  chronic,  affecting  either  of  the  parts  alone, 
or  all  at  one  and  the  same  time.  Itching  is  a  constant  and  annoying 
symptom. 

The  diagnosis  is  to  be  made  between  eczema  of  these  parts  and 
psoriasis  or  syphilis. 

Treatment.  The  plan  of  Hebra  for  eczema  rubrum  will  usually  be 
successful  for  this  variety.     The  following  formula  is  also  valuable  : — 

H.     Hydrargyri  oleat.  5-15  per  cent., ^iv 

Olei  cadini, ^ss 

Cerat.  simp., ^iv.  M. 

SiG. — Rub  well  into  part  morning  and  night,  first  macerating  with  hot 
water. 

Eczema  tmguium.  The  nails  are  seldom  attacked  alone,  but  in 
connection  with  eczema  manuum.  The  symptoms  are  roughness, 
want  of  polish,  unevenness  and  a  punctate  or  honeycomb  appear- 
ance similar  to  that  seen  in  psoriasis  of  the  nails.  The  nail  becomes 
depressed,  particularly  at  its  root,  thus  interfering  with  its  nutrition, 
resulting  in  loss  of  this  appendage. 

Treatment.  Internally  arsenicum  is  of  the  greatest  value.  Locally, 
the  following  : — 

R.     Ung.  picis  liq., ^iv 

Hydrargyri  chlor.  mite, ^ss 

Vaselini, :5  iv.  M. 

SiG. — Apply  thoroughly. 

It  is  a  remarkable  clinical  fact,  that  very  many  cases  of  eczema, 
whether  acute,  subacute  or  chronic,  are  rapidly  cured  by  the  use  of 
potassii  iodidicm  in  variable  doses. 

URTICARIA. 

Synonyms.     Hives ;  nettle-rash. 

Definition.  An  inflammation  of  the  skin  characterized  by  the 
development  of  wheals  of  a  whitish,  pinkish  or  reddish  color,  accom- 
panied by  stinging,  pricking  and  tingling  sensations. 


DISEASES   OF  THE  SKIN.  397 

Causes.  Very  frequently  the  result  of  sudden  surface  hyperaemia, 
or  rather  too  rapid  circulation  through  the  superficial  capillaries,  the 
result  of  exposure  to  heat.  Irritants  and  poison  produce  an  attack 
when  brought  in  contact  with  the  skin.  Gastric,  intestinal,  hepatic, 
nephritic,  ovarian,  uterine  and  cystic  derangements  are  very  frequent 
causes.  Certain  medicaments;  malaria;  nervous  disorders;  asso- 
ciated with  purpura  and  rheumatism  ;  pregnancy  ;  lactation  ;  meno- 
pause. 

Patholog'y.  An  acute  inflammation  of  the  papillary  layer  of  the 
skin  ;  characterized  by  the  rapid  development  of  a  "wheal  " — a  more 
or  less  firm  elevation — consisting  of  a  circumscribed  collection  of  a 
semi-fluid  material,  the  result  of  a  rapid  exudation  into  the  upper 
layers  of  the  skin.  The  production  of  the  wheal  is  the  immediate 
result  of  a  disturbance  of  the  vaso-motor  system,  which  is  shown  by 
the  interference  of  the  circulation  in  the  wheal,  the  blood  being 
driven  from  its  centre  to  its  periphery,  causing  the  whitish  apex  and 
red  areola,  so  characteristic  of  the  developed  wheal. 

Symptoms.  An  attack  of  "hives"  is  characterized  by  the  sud- 
den development  of  w-^^^xA  upon  the  cutaneous  surface,  which  usually 
as  suddenly  disappear,  their  site  being  temporarily  marked  by  a  spot 
of  redness  or  hyperaemia. 

With  the  appearance  of  the  wheal  occur  distressing  itching,  burn- 
ing,  tiftgiing,  crawling,  pricking  and  stinging  sensations,  to  relieve 
which  the  patient  still  further  irritates,  tears  or  otherwise  wounds  the 
surface  by  scratching,  whence  are  often  developed  deep-colored,  flat, 
lenticular  papules. 

Very  frequently  an  attack  of  "  hives  "  is  associated  with  fever,  head- 
ache and  gastric  disorder.  The  "wheals"  may  appear  upon  any 
portion  of  the  body  ;  their  size  varies  from  that  of  a  pea  to  that  of  a 
walnut  or  an  ^^g — the  "  giant  wheals;"  the  number  varying  from  a 
very  few  to  being  so  numerous  as  to  cover  the  whole  surface  of  the 
body.  The  shape,  size,  color  and  number  of  the  wheals  that  may  occur 
in  any  given  case  have  given  rise  to  a  number  of  names  to  designate 
the  lesions.  Thus,  urticaria  ajimilaris  occurs  in  rings  ;  urticaria 
figurata  occurs  in  spirals  ;  urticaria  vesiculosa  has  a  vesicular  devel- 
opment on  the  summit  of  the  wheal ;  urticaria  bullosa,  a  bullous 
development  at  the  summit ;  urticaria  papulosa  or  lichen  urticatus, 
the  wheal  and  a  small  papule  are  combined  ;  tirticaria  tuberosa,  or 


398  PRACTICE   OF   MEDICINE. 

g^ant  wheals  ;  urticaria  hemorrhagica  or  ptirpiirata  urticaria,  a  com- 
bination of  urticaria  and  purpura  ;  urticaria  evanida,  a  rapid  appear- 
ance and  disappearance  of  the  lesion  ;  urticaria  perstans,  slow  dis- 
appearance ;  urticaria  cofiferta,  when  the  wheals  are  confluent ; 
urticaria  pigmentosa,  where  the  wheals  are  succeeded  by  pigmenta- 
tions of  the  site,  the  tints  varying  from  dark  brown,  greenish  yellow, 
to  a  chocolate  color ;  urticaria  febritis,  when  the  wheals  are  associated 
with  fever;  urticaria  ab  ingestis,  when  associated  with  indigestion. 

Treatment.  To  prevent  the  recurrence  of  the  disorder  a  thorough 
investigation  of  the  cause  must  be  made,  and  when  found  (not  always 
possible)  be  removed. 

Attention  should  be  directed  to  the  state  of  the  general  health,  the 
diet  and  the  secretions. 

Thie  following  remedies,  alone  or  variously  combined,  are  often  of 
benefit :  quinina,  sodii  saiicylas,  pilocarpus,  airopina,  tinctura  bella- 
donnce,  ajiiinonii  chloridutn,  arsenicuni  and  potassii  bromiduin.  The 
following  pill  is  valuable  in  many  cases  : — 

R .     Pulv.  pilocarpus, 

Ext.  guaiaci, aa gr.  iss 

Lithii  benzoat., gr.  iij.  M. 

SiG  — Two  to  four  each  twenty-four  hours. 

If  there  be  atonic  dyspepsia  and  constipation,  the  following  com- 
bination is  useful : — 

li  .     Magnesii  sul])hat., 3J 

Ferri  sulphat., gr.  xvj 

So'iii  chloridi, '^s% 

Acidi  sulphuric!  dil., f  ^^5  ij 

Inf.  cascarillne, f  Jiv.  M. 

SiG. — Tablespoonful  before  breakfast,  diluted. 

Z^r<2/ measures  are  of  the  greatest  value,  either  as  baths,  lotions  or 
dusting  powders.  The  following  are  among  the  most  serviceable  ; 
sponging  with  alcohol,  brandy,  whisky,  vinegar  and  water,  salt  water, 
alkaline  baths  and  ^^/c/ baths.    Duhring  recommends  the  following: — 

Ijt .     Acidi  cnrliolici, 3  iss 

Glyc<-'rini, f,^ij 

Alcoholis, f.^viij 

Aq.  amygdal   amar., fjviij.  M. 

SiG. — Use  as  lotion,  two  or  three  limes  daily. 


DISEASES   OF  THE   SKIN.  399 

Bulkley  suggests  the  following  : — 

R .     Chloralis, 

Camphorae, aa  .    .    .    .     f^j 

Misce,  and  rub  and  incorporate  with 

Pulveris  amyli, ,lj~ij- 

Misce,  and  keep  tightly  corked  in  a  wide-mouthed  bottle. 

SiG. — Rub  in  with  hand. 

A  serviceable  formula  is  the  following : — 

R.     Chloroformi, f^'] 

Ung.  zinci  oxid., ^\].  M. 

SiG. — Apply  with  hand. 

HERPES. 

Definition.  An  acute  inflammation  of  the  skin  ;  characterized  by 
the  development  of  one  or  more  groups  oi  vesicles,  filled  with  a  clear 
serum,  occurring  for  the  most  part  about  the  face  {herpes  facialis) 
and  genitalia  {herpes  progenitalis). 

Causes.  Herpes  facialis  :  during  the  course  of  febrile  and  nervous 
disorders ;  in  connection  with  digestive  disorders  and  colds. 

Herpes  progenitalis ;  the  origin  is  local,  from  uncleanliness  or 
friction. 

Pathology.  Hebra  defines  the  various  forms  of  herpes  as  "a 
series  of  acute  cutaneous  diseases  of  cyclical  course,  marked  by  an 
exudation  which  collects  in  drops  under  the  epidermis  and  elevates 
it ;  forming  vesicles  which  are  never  solitary,  but  always  appear  in 
groups." 

Symptoms.  The  appearance  of  the  vesicles  is  usually  preceded 
by  a  feeling  of  heat  in  the  region,  together  with  slight  tumefaction  or 
swelling.  Rarely  the  herpetic  attack  is  attended  with  malaise  and 
pyrexia. 

The  eruption  usually  appears  in  the  form  of  a  small  cluster  of  pin- 
head  to  split-pea-sized  vesicles,  containing  a  clear  fluid,  becoming 
cloudy,  afterward  puriform  and  dries  in  small,  yellowish  or  brownish 
crusts;  they  are  few  in  number  and  may  coalesce.  They  disappear 
without  leaving  a  scar. 

Herpes  facialis ;  occur  upon  any  portion  of  the  face,  but  most 
frequently  about  the  lips — herpes  labialis:  The  alee  of  the  nose, 
auricles  and  the  mucous  membranes  of  the  mouth  and  tono-ue  are 


400  PRACTICE   OF   MEDICINE. 

frequent  locations,  in  the  latter  appearing  as  excoriated  patches  from 
rupture  of  the  vesicles. 

Herpes  progenitalis ;  in  the  male  the  chief  site  is  the  prepuce 
{herpes prcFputialis).  In  the  female  they  are  comparatively  rare  ;  but 
when  occurring  it  is  upon  the  labia  majora  and  minora  and  the  skin 
about  the  vulva. 

This  variety  is  preceded  by  burning,  itching  or  neuralgic  pains, 
accompanied  with  redness,  congestion  and  more  or  less  cedema. 

The  lesion  in  these  parts  is  likely  to  be  mistaken  for  one  form  or 
other  of  venereal  disease. 

Herpes  gestationis  ;  a  rare  affection  of  the  skin  occurring  during 
pregnancy,  consisting  of  erythema,  papules,  vesicles  and  bullae, 
attended  with  intense  burning  and  itching.  It  may  appear  at  any 
time  of  pregnancy  up  to  the  seventh  month,  and  continues  until  some 
time  after  delivery. 

Treatment.  Herpes  facialis  seldom  calls  for  treatment,  although 
in  marked  cases  of  herpes  labialis  protection  with  liquor  gutta-percha 
or  collodium  flexile  promote  desiccation. 

Herpes  progenitalis  ;  cleanliness  is  of  the  first  importance.  Coat- 
ing the  eruption  with  the  medicaments  mentioned  above  or  washing 
with  a  saturated  solution  of  aciduin  boraciciim,  and  afterward  dusting 
with  hydrargyri  chloridum  mite,  are  useful. 

The  parts  may  be  rendered  less  sensitive  in  frequently  recurring 
cases  by  astringent  lotions,  as  aciduui  ta?inicum  or  zinci  sulphas. 
Circumcision,  where  required,  may  be  practiced. 

HERPES    ZOSTER. 

Synonyms.     Zona  ;  shingles  ;  a  girdle ;  intercostal  neuralgia. 

Definition.  An  acute,  inflammatory  disease;  characterized  by 
the  development  of  groups  of  firm  and  distended  vesicles  situated 
upon  inflamed  bases  corresponding  to  a  definite  nerve  trunk,  and 
accompanied  by  more  or  less  severe  neuralgic  pains. 

Causes.  The  eruption  and  consequent  neuralgic  pains  are  the 
immcdij.lc  result  of  an  inflammation  of  the  ganglia  or  of  the  nerve 
trunks  and  branches — a  neuritis — probably  of  the  trophic  fibres  of 
the  affected  part ;  but  the  cause  producing  this  condition  is  obscure. 
Among  the  many  that  have  been  suggested  are  :  cold,  injuries  to 
nerves,  anaemia,  and  the  medicinal  use  of  arsenicum. 


DISEASES   OF  THE  SKIN.  401 

Pathology.  An  inflammation  of  either  the  gangha,  the  nerve 
trunk  or  branches — probably  the  trophic  system — causing  the  devel- 
opment of  vesicles  in  the  lower  strata  of  the  rete,  with  "the  infiltra- 
tion of  serum  and  inflammatory  cells  "  of  the  papillae  and  corium. 

Symptoms.  Begins  with  neuralgic  pains,  either  of  a  burning  or 
lightning-like  character,  with  slight  febrile  phenomena,  followed  by 
the  appearance  oi  papulovesicles  alotig  the  tract  of  pain  ;  these  soon 
become  vesicles  situated  on  bright  red,  highly-inflamed  bases.  The 
vesicles  are  about  the  size  of  pin  heads,  or  perhaps  a  little  larger, 
usually  discrete,  although  they  frequently  coalesce,  forming  irregular 
patches,  coming  in  groups  until  the  third  to  the  fifth  or  even  tenth  day, 
when  they  gradually  desiccate,  and  at  the  end  of  the  second  week 
nothing  remains  but  a  slight  scar,  which  may  also  disappear  after  a 
time  or,  rarely,  is  permanent. 

When  the  eruption  is  at  its  height  it  is  perfect  in  its  anatomical 
formation,  each  vesicle  being  well-shaped  and  seated  on  a  bright  red, 
inflamed  patch  of  skin,  and  distended  with  a  translucent,  yellowish 
fluid. 

The  eruption  is  almost  invariably  confined  to  one  side  (unilateral) 
of  the  body,  although,  in  rare  instances,  it  is  seen  upon  both  (bi- 
lateral) sides.  It  is  usually  found  upon  well-known  nerve  tracts. 
According  to  the  region  affected  it  is  termed  zoster  capitis,  zoster 
frontalis,  zoster  faciei,  zoster  ophthalmicus,  zoster  auricularis,  zoster 
nuc  hcB,  zoster  brachialis,  zoster  pectoralis,  zoster  abdominalis,  zoster 
femoralis. 

In  the  very  young  the  eruption  may  develop  and  pursue  its  course 
without  the  neuralgic  pains. 

Diagnosis.  The  characteristics  of  herpes  zoster  or  shingles  are 
usually  so  well  marked  that  an  error  in  diagnosis  should  not  occur. 
The  neuralgic  pain  preceding  the  eruption  and  its  development  in 
distinct  groups  upon  inflamed  bases  following  a  nerve  tract  are  so  dif- 
ferent from  simple  herpes  of  the  face,  or  genitalia,  or  from  the  lesion 
of  eczema. 

Prognosis.  Favorable.  Tlie  affection  is  self-limited,  the  dura- 
tion being  about  two  weeks.  It  is  said  that  "  zoster  of  the  orbital 
region  may  seriously  involve  the  eye  and  prove  fatal." 

Treatment.  The  affection  being  self-limited,  it  follows  that  reme- 
dies to  cut  it  short  are  useless.  The  following  combination  diminishes 
the  pain  and  modifies  the  duration  : — 


402  PRACTICE   OF   MEDICINE. 

R .     Zinci  phosphidi, 

Ex.  nucis  vom., aS. gr.  x. 

M.  et  ft.  pil.  No.  XXX. 
SiG. — One  every  two  to  four  hours.     (Bulkley.) 

Prof.  Bartholow  "has  seen  excellent  results  in  cases  of  shingles 
from  galvanization  of  the  affected  intercostal  nerves — the  positive 
pole  being  placed  over  the  point  of  emergence  of  the  nerves,  and  the 
negative  brushed  over  the  terminal  filaments  in  the  skin." 

The  general  symptoms  are  to  be  treated  as  indicated.  Anaemia  or 
depression  are  benefited  by  full  doses/erri  et  quinines  citras. 

For  the  pain  no  remedy  seems  comparable  with  the  hypodermic  use 
of  morphincE  siilph.,  gr.  Y^-Yi  with  atropiiia  sn/ph.,  gr.  yi^,  near  the 
lesion.  Antipyrine ,  gr.  xv,  repeated  every  three  or  four  hours,  relieves 
the  pain  in  many  cases. 

Locally,  relief  follows  coating  the  "  shingles"  with  either  collodium 
flexile  or  liquor  gutta-perchcE,  to  which  inorphincE  sulphas  may  be 
added. 

MILIARIA. 

Synonyms.  Lichen  tropicus ;  miliaria  rubra ;  miliaria  alba ; 
prickly  heat. 

Definition.  An  acute  inflammation  of  the  sweat  glands ;  char- 
acterized by  the  development  of  discrete,  whitish  or  reddish,  pin-point 
and  millet-seed-sized  papules,  vesicles  or  vesiculo-papules,  productive 
of  pricking,  tingling  and  burning  sensations  of  a  most  aggravated 
character. 

Causes.  Excessive  heat,  the  result  of  excessive  or  tightly-fitting 
clothing,  or  a  high  external  temperature.  Most  common  in  fleshy 
adults  who  perspire  freely,  and  in  children.  Nervous  prostration  ; 
severe  dyspepsia  and  general  debility  seem  to  predispose  to  "  prickly 
heat." 

Varieties.     Miliaria  papulosa  ;  tniliaria  vesiculosa. 

Pathology.  The  pathology  of  the  two  varieties  is  the  same,  both 
being  inflammatory  affections  of  the  sweat  glands  ;  in  the  one  papules, 
and  in  the  other  vesicles  develop  about  the  orifices  of  the  excretory 
ducts. 

In  either  variety  there  occurs  hyperaemia  of  the  vascular  plexus  of 
the  sweet  gland,  followed  by  slight  exudation  about  the  ducts,  giving 
rise  to  the  minute  papule  or  vesicle,  which  remain  until  the  cause  has 
been  modified  or  removed,  when  they  are  rapidly  absorbed. 


DISEASES   OF  THE   SKIN.  403 

Symptoms.  Miliaria  papulosa;  known  as  lichen  tropicus  and 
"prickly  heat,"  is  of  sudden  onset,  with  the  occurrence  of  numerous 
minute,  acuminated  bright  red  papules,  about  the  size  of  a  pin  head 
or  millet-seed,  and  but  slightly  raised  above  the  level  of  the  skin. 
The  papules  are  preceded  by  and  accompanied  with  sweating  (hyperi- 
drosis),  and  distressing  tijigling,  pricking  and  burning  sensations. 
If  the  attack  be  severe,  vesico-papules  and  vesicles  are  freely  inter- 
spersed among  the  numerous  papules. 

Miliaria  vesiculosa  ;  in  this  variety,  instead  of  papules,  immense 
numbers  of  vesicles  develop,  of  the  size  of  pin  points  and  pin  heads, 
of  a  whitish  {miliaria  alba)  or  yellowish-white  color.  The  surface 
from  which  they  arise  is  of  a  bright-red  color,  owing  to  each  vesicle 
being  surrounded  by  an  areola  {miliaria  rubra).  The  vesicles  are 
preceded  and  accompanied  with  sweating  (byperidrosis)  and  most 
distressing,  tingling,  pricking  and  burning  sensations. 

Either  variety  may  attack  all  parts  of  the  body,  but  the  abdomen, 
chest,  back,  neck  and  arms  are  the  regions  usually  invaded. 

Duration.  This  varies  with  the  cause.  It  may  appear,  fully 
develop  and  disappear  in  a  few  hours.  In  those  predisposed,  it  may 
continue  more  or  less  marked  throughout  the  entire  summer. 

Diagnosis.  If  the  cause,  nature  and  seat  of  the  affection  are 
taken  into  consideration,  no  error  should  occur. 

Eczema  papulosum  has  a  resemblance  to  "  prickly  heat,"  but  the 
course  of  eczema  is  slov/,  and  the  papules  are  larger,  more  elevated, 
and  firmer  than  those  of  miliaria  papulosa. 

Eczema  vesiculosum  and  miliaria  vesiculosa  are  to  be  differentiated 
by  the  marked  differences  in  the  progress  of  each,  the  former  slow, 
the  latter  rapid,  the  vesicles  of  the  former  rupturing  spontaneously, 
those  of  the  latter  only  when  severely  irritated. 

Sudamen  is  not  an  inflammatory  affection,  while  miliaria  is. 

Prognosis,  The  affection  is  often  most  rebellious  in  fleshy  per- 
sons and  children,  and  if  neglected  it  passes  into  eczema  or  an 
erythematous  intertrigo. 

Treatment.  The  patient  should  be  kept  as  cool  as  possible,  and 
avoid  undue  perspiration.  The  fears  entertained  by  the  laity,  of 
danger  from  retrocession  of  the  eruption,  are  groundless  ;  the  sooner 
it  disappears  the  better  for  the  comfort  of  the  patient, 

The  food  should  be  light  and  unstimulating;  wine,  spirits  and  beer 
are  to  be  avoided. 


404  PRACTICE   OF   MEDICINE. 

The  ingestion  of  water,  lemonade,  Apollinaris  water,  Vichy  water, 
together  with  refrigerant  diuretics,  as  potassii  citrus  vel  acetas,  a  cool 
apartment,  and  absolute  rest  will  ordinarily  insure  speedy  relief. 

Locally;  sponging  vf'iXh  alkaline  XoXions,  liquor plumbi  subacetatis 
dilutiis,  extracttim  grittdelicE  fiuiduiti  well  diluted,  or  cupri  sulphas, 
in  solution  (gr.  x,  agues,  f5J),  or  acidi  carbolici,  gr.  y^y.,  glyceriti  ainyli, 
^iij,  or  a  dusting  powder,  consisting  oi  lycopodiiwi,  zinci  oxidum  and 
amylum,  singly  or  combined. 

PEMPHIGUS. 

Synonym.    Water  blisters. 

Definition.  An  inflammatory  disease  of  the  skin,  either  acute 
or  chronic,  characterized  by  the  development  of  a  succession  of 
rounded,  irregular-shaped  blebs  or  bullae,  varying  in  size  from  a  pea 
to  an  tgg. 

Varieties.     Pemp  higus  vulgaris ;  pemphigus  foliaceus. 

Cause.  Obscure.  It  is  usually  associated  with  a  depressed  state 
of  the  general  system  ;    disorders  of  menstruation  ;  during  pregnancy. 

Pathology.  Hebra  thus  describes  the  appearance  of  the  blebs: 
"Sometimes  a  circumscribed,  hght-red  spot  appears,  perhaps  of  the 
size  of  a  bean  or  a  large  coin  ;  this  is  paler  in  the  centre,  and  may  even 
present  a  tinge  of  white,  indicating  the  point  at  which  the  bleb  is  to 
form,  and  from  which  it  will  spread  outward  over  the  surrounding 
skin,  and,  in  fact,  is  at  first  a  wheal,  passing  afterward  into  a  bleb* 
In  other  cases  the  bleb  is  not  preceded  either  by  a  red  spot  or  by  a 
wheal,  but  b  egins  originally  as  a  small  collection  of  clear  fluid  beneath 
the  cuticle.  Thus,  hyperaemia  of  the  skin  may  exist  before  exudation 
is  poured  out,  or  the  latter  may  be  formed  before  any  congestion  of 
the  papillary  layer  is  discoverable." 

The  contents  of  the  blebs  or  bullae  are  yellowish  or  colorless  serum, 
of  a  neutral  or  alkaline  reaction,  the  older  the  fluid  the  more  alkaline 
it  becomes.  In  the  late  stages  of  a  bleb  the  fluid  becomes  puriform. 
In  rare  instances  blood  is  contained  in  the  bleb  (pemphigus  hemor- 
rhagicus). 

Symptoms.  Pemphigus  vulgaris ;  the  onset  is  slow  {^pemphigus 
chronicus),  without  constitutional  symptoms,  or  acute  {pemphigus 
acutus)  preceded  by  febrile  reaction.  The  lesions  are  the  successive 
development  of  blebs,  usually  from  half  a  dozen  to  a  dozen,  varying 
in   size  from  a  pea  to  an  tgg,  of  a  round  or  oval  shape,  their  walls 


DISEASES   OF  THE  SKIN.  405 

distended  with  a  colorless  fluid,  the  color  becoming  yellowish  or  puri- 
form  as  they  grow  older.  They  develop  abruptly  from  the  sound 
skin,  with  a  definite  hne  of  demarcation,  unattended  with  symptoms 
of  inflammation.  A  characteristic  phenomena  of  the  lesion  is  their 
successive  appearance  ;  a  crop  no  sooner  disappears  than  another 
forms,  throughout  the  course  of  the  affection,  each  crop  running  its 
course  in  from  three  to  six  or  ten  days.  With  the  appearance  of  the 
blebs  occur  itching  and  burning,  usually  of  a  mild  character,  although 
occasionally  in  a  distressing  degree  (^pemphigus  pruriginosus). 

Pemphigus  maligmis  is  characterized  by  the  great  size  and  number 
of  the  blebs,  which  coalesce,  rupture  and  are  succeeded  by  excoriated 
surfaces  which  occasionally  take  on  ulcerative  action,  the  patient's 
health  being  seriously  impaired. 

Pe^nphigus  foliaceus  differs  from  pemphigus  vulgaris  in  that  the 
blebs,  instead  of  being  distended  or  tense,  are  flaccid  and  only  par- 
tially filled  with  fluid,  as  they  rupture  before  arriving  at  their  state  of 
full  development.  This  variety  also  appears  and  disappears  in  crops. 
After  rupture  the  fluid  immediately  dries  into  thin  whitish  flakes, 
which  are  detached  in  quantity,  leaving  a  red,  excoriated  surface — 
the  rete  and  corium.  If  the  affection  has  continued  for  some  time, 
the  skin  presents  the  appearance  of  a  superficial  scald.  The  course 
of  this  variety  is  essentially  chronic. 

All  portions  of  the  body  are  liable  to  the  lesion,  as  also  the  mucous 
membrane  of  the  mouth  and  vagina.  It  is  most  common,  however, 
upon  the  limbs. 

Diagnosis.  In  a  typical  case  no  difficulty  should  be  experienced 
in  making  a  diagnosis.  The  mere  presence  of  blebs,  however,  does 
not  necessarily  constitute  pemphigus,  for  it  must  be  remembered  that 
they  are  at  times  developed  in  other  diseases  as  well  as  by  artificial 
means ;  the  appearance  of  blebs  in  crops  is  a  strong  diagnostic  point. 

Prognosis.  The  course  of  the  affection  is  most  uncertain,  and 
relapses  are  frequent.  In  arriving  at  an  opinion,  the  occurrence  of 
fatal  cases  must  not  be  forgotten. 

Treatment.  Attention  to  the  general  health  of  the  patient  is  of 
the  greatest  moment.  A  careful  study  of  the  cause  should  be  made, 
and  if  determined,  means  for  its  removal  are  of  the  first  importance. 

Two  remedies,  arsenicuni  and  guinina,  are  of  great  value,  the  secret 
of  success  being  the  persistent  use  of  the  former ;  or  if  the  latter  be 
used,  the  dose  should  be  large. 


406  PRACTICE   OF   MEDICINE. 

Local  measures  are  also  of  importance.  The  blebs  should  be 
punctured  and  evacuated  as  soon  as  formed.  The  use  of  dusting 
powders  of  zinci  oxiditm,  ainylum,  or  violet-powder,  or  lotions  of 
liquor plumbi  subacetatis  dilutuvi,  are  valuable. 

Hebra  recommends  the  continuous  bath. 


IMPETIGO. 

Definition.  An  acute  inflammatory  disease,  characterized  by  the 
development  of  one  or  more  discrete,  rounded  and  elevated  firm 
pustules,  about  the  size  of  a  pea,  unattended  with  itching. 

Causes.  Occurs  for  the  most  part  between  the  ages  of  three  and 
ten  years,  in  the  well  nourished  and  healthy.  It  is  not  associated 
with  eczema.     It  is  not  contagious. 

Pathology.  The  lesion  is  a  well-formed,  typical  pustule,  develop- 
ing abruptly  from  the  surface,  containing  a  whitish-yellow  fluid,  pus 
corpuscles,  blood  corpuscles,  epithelial  cells  and  cellular  detritis. 
The  abscess  or  pustule  is  about  the  size  of  a  pea,  circumscribed  and 
superficial. 

Synonyms.  The  affection  manifests  itself  by  the  development 
of  from  one  or  two  to  a  dozen  or  more  ^\si\xiz\.  pustules,  about  the  size 
of  a  split  pea,  of  a  rounded  shape,  raised  above  the  surface,  with  thick 
walls,  of  a  yellowish  or  whitish  color,  surrounded  by  a  distinct  areola, 
which  soon  fades,  are  without  a  central  depression  or  umbilication, 
and  unattended  with  either  itching  or  burning. 

The  affection  runs  an  acute  course,  usually  lasting  a  couple  of 
weeks.  The  pustules,  after  attaining  their  full  size,  remain  stationary 
for  a  few  days,  when  they  disappear  by  absorption  and  desiccation, 
the  crusts  dropping  off,  displaying  a  reddish  base,  which  soon  dis- 
appears with  pigmentation  or  scar. 

The  pustules  occur  on  all  portions  of  the  body,  the  most  frequent 
locations  being  the  face,  hands,  fingers,  feet,  toes  and  lower  extremities. 

Diagnosis.  Impetigo  is  unassociated  with  general  symptoms, 
and  its  particular  lesion — the  pustule — is  discrete,  points  of  import- 
ance in  the  diagnosis. 

Eczema  pustulosum  is  also  a  pustular  affection,  but  the  large  num- 
ber, their  disposition  to  coalesce,  their  location  upon  an  inflammatory 
base,  their  rupture  and  subsequent  crusting  and  itching,  are  diag- 
nostic points. 


DISEASES   OF  THE   SKIN.  407 

The  diagnostic  points  from  ecthyma  will  be  pointed  out  when 
describing  that  affection. 

Prognosis.     Favorable. 

Treatment.  The  pustules  should  be  opened  as  soon  as  they 
mature,  the  contents  removed  by  washing  with  tepid  water  and 
soap,  and  the  floor  covered  with  hydrargyri  chloridum  mite  or  zinci 
oleat. 

Coating  the  pustules  with  coUodiuin  fiexile  or  liquor  gutta-perchce, 
if  they  are  located  where  irritation  be  liable,  is  a  valuable  mode  of 
treatment. 


ECTHYMA. 

Definition.  An  affection  of  the  skin,  characterized  by  the  forma- 
tion of  one  or  more  large,  isolated,  flat  pustules,  situated  upon  an 
inflammatory  base. 

Cause.  It  is  most  common  among  those  who  live  in  squalor  and 
poverty,  and  in  delicate  and  poorly-nourished  children.  Improper 
and  insufficient  diet,  want  of  ventilation,  excessive  work,  and  un- 
cleanliness  are  all  prominent  causes. 

Pathology.  The  lesion  is  a  typical  postular  process,  severe  but 
superficial,  and  not  extending  beyond  the  papillary  layer  of  the 
corium.  The  pustule  is  situated  upon  a  firm  and  highly-inflamed 
base ;  the  number  varies  from  one  to  a  dozen  or  more. 

Symptoms.  The  disease  is  characterized  by  the  development  of 
one  or  more  round  or  oval,  yet  flat,  pustules  about  the  size  of  a  pea- 
bean,  attended  with  a  moderate  heat,  hurtling  and  pain,  and  if  the 
number  be  large,  slight  febrile  reaction.  The  pustules  are  first 
yellowish  in  color,  surrounded  by  a  firm  and  sensitive  bright-red 
areola,  the  pustule  afterward  becoming  reddish  from  the  admixture  of 
blood,  soon  drying  into  flat  crusts  of  a  brownish  color.  The  dura- 
tion of  each  pustule  is  between  two  and  three  weeks,  new  ones  form- 
ing, until  the  cause  is  removed. 

The  most  prominent  sites  are  the  thighs,  legs,  shoulders,  and  back. 

Diagnosis.  Ecthyma  and  eczema  pustulosum  have  points  of 
resemblance,  but  a  study  of  the  clinical  history  of  the  latter  should 
prevent  error. 

Impetigo  differs  from  ecthyma  in  the  size  of  the  pustule  and  crust. 

Ecthyma  differs  from  a  boil  in  not  having  a  central  core. 


408  PRACTICE   OF   MEDICINE. 

Prognosis.  With  care  and  the  removal  of  the  cause,  recovery  is 
always  prompt. 

Treatment.  The  general  treatment  of  the  patient  is  of  the  first 
importance.  Nutritious  and  wholesome  food,  cleanliness,  bathing, 
fresh  air  and  regulated  exercise  should  be  advised,  together  with  such 
tonics  3.sfernnn,  arseniciim,  quinma,  strychnina  and  mineral  acids. 

Locally  :  remove  the  crusts  by  first  soaking  with  oil  or  fat,  or  water 
dressings,  and  apply — 

R.     Ungt.  zinci  oxid.  benz., 5ss 

Vaselini, ^ss 

Hydrargyri  ammoniati, 3  J-  M. 

Ft.  ungt.  — DUHRING. 

Pustules  showing  a  sluggish  disposition  to  heal  should  be  stimulated 
by  touching  with  either  argenti  nitras  or  acidum  carbolicum. 


FURUNCULUS. 

Synonyms.     Furunculosis  ;  furuncle  ;  boil. 

Definition.  An  acute  affection  of  the  skin,  characterized  by  the 
occurrence  of  one  or  more  circumscribed  cutaneous  or  subcutaneous 
abscesses  (boils),  which  usually  terminate  by  necrosis  of  the  central 
tissue,  its  subsequent  expulsion  in  the  form  of  pus  or  a  core,  and  a 
resulting  cicatrix. 

Cause.  The  result  of  a  depraved  condition  of  the  system,  induced 
by  general  debility,  excessive  fatigue,  nervous  depression,  improper 
food  and  exercise,  anaemia,  diabetes,  uraemia,  or  the  result  of  local 
friction,  pressure  or  contusions. 

Pathology.  The  process  resulting  in  a  "boil"  has  its  origin  in 
either  a  sebaceous  gland,  a  sweat  gland,  or  a  piliary  follicle,  and  never 
begins  in  the  meshes  of  the  corium.  "  It  begins  as  a  small,  roundish 
spot,  which  increases  in  size  until  certain  dimensions  are  attained, 
when  it  undergoes  suppurative  change,  resulting  in  the  formation  of  a 
central  point  or  core,  composed  of  the  tissue  of  the  gland  in  which 
the  furuncle  originated,  which,  together  with  the  pus,  is  cast  off.  It  shows 
no  disposition  to  become  diffuse,  being  always  a  circumscribed  in- 
flammation. After  the  discharge  of  the  core,  a  cavity  of  more  or  less 
depth  remains,  showing  the  tissues  around  it  to  be  hard  and  infiltrated. 
After  a  few  days  or  a  week  it  fills  up  by  granulation,  leaving  a  cicatrix, 


DISEASES   OF  THE   SKIN.  409 

which  is  often  permanent.  The  central  point  or  core,  when  thrown 
off,  is  composed  of  a  whitish,  tough,  pultaceous  mass  of  dead  tissue, 
varying  in  size  with  the  extent  and  depth  of  the  inflammation." 
(Duhring.) 

Hydro-adenitis,  as  seen  in  the  axillae,  around  the  nipples  and  about 
the  anus  or  perineum,  differs  from  the  ordinary  "boil "  merely  in 
being  deeper  seated. 

Syraptoms.  "Boils"  may  occur  singly,  or  more  commonly  in 
crops  of  two,  three  or  more,  another  crop  following  their  disappear- 
ance {furunculosis). 

The  abscess  begins  as  a  small,  rounded,  imperfectly  defined,  isolated, 
reddish  spot,  of  a  highly  inflamed  character,  painful  on  presstire,  its 
size  gradually  increasing,  its  central  point  presenting  evidences  of 
suppuration.  It  reaches  its  full  development  in  about  a  week,  when 
it  consists  of  a  slightly  raised,  rounded  and  pointed  inflammatory 
swelling  with  a  yellowish  point  in  the  centre — the  "  core."  Abscesses 
with  no  central  suppuration  or  core  are  called  "blind  boils."  The 
size  of  a  developed  boil  varies  from  a  split  pea  to  a  walnut,  the  color 
deep  red,  with  a  yellow  centre,  and  is  surrounded  by  a  slight  areola. 
The  pain  of  a  boil  is  dull  and  throbbing,  painful  on  pressure,  and  is 
usually  worse  at  night.  The  constitutional  symptoms  are  mild  or 
severe,  according  to  the  number  and  size  of  the  lesions. 

Any  portion  of  the  body  may  be  attacked  ;  its  preference,  however, 
is  for  the  face,  neck,  back,  axillae,  nipples,  buttocks,  anus,  perineum 
and  labias. 

Diagnosis.  The  characteristics  of  furuncle  are  so  marked  that 
an  error  seems  im.possible.  It  may  be,  however,  mistaken  for  car- 
buncle, the  differences  between  which  will  be  pointed  out  when  dis- 
cussing that  affection. 

Prognosis.  No  danger  results  from  occasional  boils,  but  when 
occurring  in  crops  they  impair  the  general  health  and  are  rebellious 
to  treatment. 

Treatment.  The  treatment  of  a  single  boil  is  well  expressed  in 
the  word  "  time  ;  "  warm  applications  are  said  to  hasten  the  stage  of 
suppuration,  and  when  reached  an  incision  permits  the  expulsion  of 
the  "  core,"  after  which  the  cure  soon  follows.  If  the  lesion  is  located 
where  friction  or  pressure  is  likely,  protection  by  either  covering  with 
adhesive  or  soap-plaster,  smoothly  spread,  is  ample. 

When,  however,  successive  crops  of  boils  occur  {^furunculosis^,  the 
34 


410  PRACTICE   OF   MEDICINE. 

treatment  should  be  both  constitutional  and  local.  The  economy  being 
below  par.  such  tonics  as  arsenicum,  quinina  ^rxd/erruni  are  of  value. 
Calcii  siilphid.,  gr.  ^^-\,  every  two  or  three  hours,  is  valuable  in  these 
cases. 

Locally,  attempts  to  abort  the  process  may  well  claim  attention, 
among  which  are  :  crucial  incisions,  to  relieve  the  tension  of  the  cen- 
tral point,  will  often  abate  the  inflammation  and  prevent  the  gangrene ; 
this  little  operation  is  rendered  painless  by  the  use  of«the  ether  spray. 
Acidiim  carbolicum,  used  in  five  per  cent,  solution,  of  which  two  to 
five  drops  injected  into  the  apex  of  the  boil,  is  valuable.  Painting 
the  forming  boil  with  argenti  tiitras  or  tinctura  iodi  are  also  recom- 
mended ;  a  paste  made  by  adding  together  equal  parts  o( glycerinum 
and  extractum  belladonncE  will  often  abort  a  boil  ;  the  same  is  also 
claimed  for  imgiieiitwn  hydrargyri  tiitratis. 


ANTHRAX. 

Synonyms.     Carbunculus  ;  carbuncle. 

Definition.  An  indurated,  more  or  less  circumscribed,  dark  red, 
painful,  deap-seated  inflammation  of  the  skin  and  subcutaneous  con- 
nective tissue,  terminating  in  a  slough  and  the  subsequent  production 
of  a  permanent  cicatrix 

Causes.  Not  positively  determined.  A  deep-seated  bruise  is  a 
supposed  cause.  Perhaps,  as  in  furuncle,  impairment  of  the  general 
health  is  the  important  factor.  It  is  generally  noted  to  occur  in 
middle  life  and  old  age,  and  in  men  more  frequently  than  in  women. 
A  "  specific"  cause  for  anthrax  is  not  an  improbable  discovery. 

Pathology.  Although  Billroth  regards  furuncle  and  carbuncle 
as  differing  only  in  degree,  the  explanation  of  Warren,  of  Boston, 
seems  the  more  probable,  he  being  the  first  to  call  the  attention  of 
histologists  "  to  the  existence  of  small  columns  of  adipose  tissue  lead- 
ing from  the  panniculus  adiposus  up  to  the  roots  of  the  lanugo  hairs, 
taking  an  oblique  direction  in  a  line  with  the  erectores  pilorum.  The 
inflammation  resulting  in  suppuration  of  the  subcutaneous  adipose 
tissue  must  either  form  an  abscess  or  become  diffuse.  In  phlegmo- 
nous erysipelas  the  latter  condition  is  observed.  But  when  the  inflam- 
mation is  in  the  dermoid  texture,  the  exudates  infiltrate  the  skin  and 
naturally  follow  the  canals  occupied  by  the  '  columniE  adiposai.'  The 
pressure  thus  exerted  upon  the  whole  dermoid  tissue  cannot  fail  to 


DISEASES    OF   THE   SKIN.  411 

Strangulate  the  circulation,  and  thus  produce  gangrene  of  the  tissue, 
even  if  the  exudate  be  not  poisonous  enough  to  destroy  the  cell  by  its 
presence.  It  can,  by  this  explanation,  be  easily  understood  why  this 
disease  is  apt  to  affect  the  skin  on  the  nape  of  the  neck  and  the  back 
more  than  on  other  parts  of  the  body.  At  this  point  the  skin  is  dense, 
its  fibrous  element  extending  deep  into  the  adipose  layer,  which  is 
surrounded  with  strong  bands ;  hence,  the  pus  confined  in  such  a 
place,  seeking  the  easiest  outlet,  will  travel  along  these  miniature 
adipose  canals,  producing  the  peculiar  appearance  pathognomonic  of 
carbuncle." 

Symptoms.  Carbuncle  is  recognized  by  its  peculiar  form  ;  com- 
mencing in  the  lower  layers  of  the  cutaneous  tissue,  it  first  resembles 
somewhat  a  phlegmon  minus  its  bright  redness.  At  first  it  is  some- 
what rounded,  with  a  strong  tendency  to  the  production  of  vesicles 
on  its  surface,  soon,  however,  becoming  firm,  circular  and  flat,  and 
raised  above  the  surrounding  parts,  spreading  through  the  subcuta- 
neous tissue  and  skin,  becoming  at  times  enormously  large,  and  having 
a  dark  red  or  violaceous  color.  As  the  disease  progresses,  the  pressure 
results  in  the  softening  of  the  tissues,  the  skin  becoming  gangrenous, 
breaking  down  at  numerous  points,  forming  perforations,  through 
which  centres  of  suppuration  appear  in  different  stages  of  advance- 
ment, either  as  whitish,  fibrous  plugs,  or  as  cavities,  from  which  a 
yellowish,  sanious  fluid  oozes,  the  surface  of  the  anthrax  having  a 
cribriform  appearance,  perforated  like  a  sieve.  The  entire  mass  ter- 
minates in  a  slough,  which,  on  being  detached,  leaves  a  large,  open, 
deep  ulcer,  with  firm,  everted  edges,  granulating  slowly,  a  permanent 
cicatrix  marking  the  site  of  the  lesion.  The  development  of  the  car- 
buncle is  attended  with  severe  paiti  of  a  deep  throbbing  2ind  burning 
character. 

The  constitutional  symptoms  vary  with  the  size,  number  and  severity 
of  the  disease  ;  loss  of  appetite,  coated  tongue,  general  malaise,  and 
moderate  febrile  reaction  accompanies  all  cases,  to  which  are  added 
those  of  septicaemia  in  severe  cases. 

The  duration  is  from  two  to  six  weeks.  Its  favorite  site  is  the  back 
of  the  neck,  shoulders,  back  and  buttocks.     It  is  usually  single. 

Diagnosis.  The  disease  is  distinguished  from  furuncle  by  its 
great  size,  its  flat  ioxxxs.,  its  course,  the  multiple  points  of  suppuration, 
and  the  character  of  the  slough.  Also  by  the  pain  ;  in  furuncle,  sen- 
sitive and  painful  to   the   touch,   carbuncle    not   being   particularly 


412  PRACTICE   OF   MEDICINE. 

sensitive.  Furuncles  generally  occur  in  numbers  or  in  crops ;  car- 
buncle is  almost  always  single. 

Prognosis.  A  guarded  opinion  should  always  be  given,  as  death 
is  not  infrequent  from  anthrax,  especially  in  elderly  people  with 
impaired  health.  The  mortality,  however,  is  not  so  great  as  the  laity 
suppose. 

A  great  danger  is  septicaemia,  from  the  action  of  the  poison  on  the 
blood,  or  the  result  of  secondary  abscesses. 

Treatment.  Constitutional  and  local  measures  are  both  of  the 
greatest  value.  Nutritious  diet,  stimulants  and  full  doses  of  such 
remedies  as  tinctura  fcrri  chloridi,  qidnitiCB  sulphas,  arsenicum  and 
aynmonii  carbonas  are  beneficial.  Good  results  are  reported  from 
calcii  stiiphid.,  gr.  y%  every  two  hours. 

Locally  ;  the  crucial  incision,  so  generally  practiced  informer  years, 
is  seldom  performed  now,  the  frequent  occurrence  of  hemorrhages 
being  too  debilitating.     The  following  are  valuable  plans: — 

Caustic  potash,  applied  to  the  carbuncle  before  an  opening  occurs, 
until  an  eschar  is  fully  formed  ;  or,  making  several  small  punctures  with 
a  scalpel  and  inserting  a  small  piece  of  caustic  potash  well  into  the 
diseased  tissue  ;  or,  if  openings  have  already  occurred,  insertion  of  the 
caustic  stick  into  them,  allowing  it  to  remain  until  melted.  By  either 
of  these  methods  I  have  seen  the  slough  cast  ofif  more  readily  than  in 
cases  where  the  crucial  incision  was  made  or  in  those  left  to  nature. 
Another  method  is,  "a  saturated  solution  of  pure  aciduju  carbolicuin 
is  injected  through  the  several  apertures  in  every  direction  into  the 
sloughing  tissues,  by  the  aid  of  an  hypodermic  syringe.  The  pain  is 
severe  but  short-lived." 

Prof.  Agnew  recommends  painting  collodiu?n  cum  cantharide  2iro\xnd 
the  anthrax,  in  the  form  of  a  broad  zone,  the  effect  of  the  blister  being 
to  relieve  the  tension.  Tinctura  iodi  is  also  used  for  a  similar  purpose. 
Hebra  advocates  cloths  wrung  out  in  ice  water,  or  ice  bags,  in  the 
early  stage,  changing  to  warm  fomentations  as  soon  as  suppuration 
has  begun.  Dr.  Ashhurst  has  practiced  with  success  the  use  of  pres- 
sure by  means  of  adhesive  plaster  applied  in  much  the  same  manner  as 
used  for  swelled  testicle.  Success  often  follows  the  application  o{  un- 
guentum  hydrargyrinitratis,  spread  at  least  one-eighth  of  an  inch  thick 
and  covered  with  adhesive  plaster,  changing  every  twenty-four  hours. 

The  resulting  ulcer,  after  expulsion  of  the  slough,  is  to  be  treated 
on  general  principles. 


DISEASES   OF  THE   SKIN.  413 

ACNE. 

Synonyms.  Acne  vulgaris;  acne  disseminata;  varus;  stone- 
pock. 

Definition.  An  inflammation,  usually  chronic,  of  the  sebaceous 
glands ;  characterized  by  the  development  of  papules,  tubercles  or 
pustules,  or  by  a  combination  of  such  lesions,  usually  in  various  stages 
of  formation,  occurring  for  the  most  part  upon  the  face. 

Varieties.     Acne  papulosa  ;  acne  pustulosa  ;  ac7ie  artificialis. 

Cause.  Not  always  understood,  as  the  affection  is  frequently 
associated  with  apparently  the  most  robust  health.  A  frequent  cause 
is  puberty.  Among  the  other  causes  observed  are  gastro-intestinal 
disorders,  anaemia,  chlorosis,  uterine  disorders,  urethral  irritation, 
scrofula,  and  the  use  of  large  doses  of  the  bromides  and  iodides. 
Acne  may  exist  alone  or  be  associated  with  comedo  or  seborrhcea. 

Pathology.  An  inflammation  of  the  sebaceous  gland  structure 
and  surrounding  tissues.  There  first  occurs  retention  of  the  sebaceous 
secretion,  which  is  soon  followed  by  hyperasmia  and  exudation  about 
the  glands  and  in  the  gland  wall  {acne papulosa),  infiltration  of  the 
connective  tissue  {acne  tubercula),  followed  by  suppuration  {acne pus- 
tulosa). If  the  inflammatory  action  be  severe,  destruction  of  the  gland 
with  a  resulting  cicatrix  occurs. 

Symptoms,  Acne  papulosa  or  acne  punctata.  This  variety  of 
the  affection  is  the  earliest  stage  of  the  inflammatory  action,  and  is 
usually  of  short  duration,  being  soon  followed  by  the  development  of 
pus.  It  is  characterized  by  the  occurrence  oi  pin-head  to  pea  size, 
flat,  more  or  less  pointed  papules,  situated  about  the  sebaceous  follicles, 
lightish  in  color,  with  a  minute  central  black  point,  the  opening  of  the 
sebaceous  duct.  Pustules  are  not  infrequently  observed  scattered 
among  the  papules.  The  lesion  is  unaccompanied  with  either  local 
or  constitutional  symptoms.  While  the  forehead  is  the  most  frequent 
seat  for  this  variety,  they  sometimes  are  seen  elsewhere. 

Acne  pustulosa.  This  is  the  fully  developed  affection.  It  is  seen 
upon  the  face,  neck,  shoulders  and  back,  as  pi?i-head  to  pea-sized, 
rounded  or  acuminated  pustules,  seated  upon  an  infiltrated,  reddish 
base  of  superficial  or  deep  inflammatory  product  {acne  induraia). 
Scattered  among  the  pustules  may  be  seen  numerous  papules.  There 
are  no  constitutional  symptoms,  nor  is  pain  complained  of  unless  the 
pustule  be  handled. 


414  PRACTICE   OF   MEDICINE. 

Acne  artificialis  is  rather  a  clinical  variety,  the  result,  usually,  of 
large  doses  of  the  bromides  or  iodides,  the  lesion  being  identical  with 
acne  pustulosa. 

Diag'nosis.  The  lesion  is  so  characteristic,  the  course  so  chronic, 
and  the  location  so  frequently  upon  the  face,  that  an  error  seems 
impossible  if  care  be  exercised. 

The  resemblance  of  the  papular  and  pustular  syphiloderms  must 
not  be  mistaken  for  acne. 

Prognosis.  Essentially  a  chronic  affection,  lasting  for  a  number 
of  years  ;  but  if  persistent  treatment  be  employed  recovery  will  occur. 

Treatment.  To  successfully  combat  an  attack  of  acne,  both  con- 
stitutional and  local  measures  must  be  employed. 

Constitutional  treatment.  The  successful  treatment  of  a  case  of 
acne  depends  upon  a  knowledge  of  its  cause  and  familiarity  with  the 
constitutional  habits  of  the  patient.  Disorders  of  digestion  and  consti- 
pation should  be  corrected.  If  anaemia  be  present, /^rrz^w  and  arseni- 
cum  are  indicated.  Scrofula  is  an  indication  for  oleum  morrhucs  and 
ferri  iodidum.  Uterine  disorders,  if  present,  should  receive  proper 
attention.  In  young  adult  males  I  have  seen  wonderful  improve- 
ment follow  the  passage  of  a  fair-sized  bougie  once  or  twice  weekly. 

Calcii  suiphid.,  gr.  xV~^>  every  two  or  three  hours,  is  valuable  in 
many  cases,  as  is  hydrargyri  chloridum  corrosivum,  gr.  x^ff-i-.V,  three 
times  daily.  A  remedy  highly  spoken  of  by  Dr.  Bulkley  is  glycer- 
inum  in  tablespoonful  doses,  two  or  three  times  daily.  Dr.  Duhring 
recommends  that  it  be  given  in  combination  with  ferri  et  quinincB 
citras.  Prof.  Bartholow  "  has  seen  excellent  results  from  the  use  of 
syrupus  hypophosphitum  comp.  in  acne  indurata." 

Local  treat7nent.  In  acne  of  not  very  long  duration  I  have  seen 
excellent  results  from  the  following  plan  :  Just  before  retiring,  the  parts 
affected  are  to  be  thoroughly  washed  with  water  as  hot  as  can  possibly 
be  borne,  and  after  the  water  has  partly  dried  the  parts  are  to  be 
thoroughly  covered  with  sulphur  sub lijnatum,  applied  by  means  of  a 
powder-puff  ball,  no  rubbing  or  friction  to  be  employed,  and  on 
arising  in  the  morning  the  sulphur  is  to  be  washed  off  with  hot  water 
and  the  face  lightly  mopped  dry,  or  what  is  better,  sulphur  again 
applied,  if  the  patient  is  willing  to  permit  it,  during  the  day. 

Dr.  Hyde  recommends  that  the  contents  of  the  papules  and  pustules 
be  evacuated  by  means  of  a  needle,  rather  encouraging  slight  bleeding, 
after  which  the  parts  are  to  be  bathed  with  water  as  hot  as  can  be 


DISEASES    OF   THE   SKIN.  415 

tolerated  ;  and  while  the  part  is  still  wet,  it  is  thoroughly  scrubbed 
with  lotio  saponis  vzridis,  then  cleansed  with  water,  carefully  dried 
and  anointed  with  a  sulphur  ointment. 

Prof.  Bartholow  suggested,  in  a  case  of  acne  indurata  seen  with 
the  author,  the  following  successful  plan.  To  dissolve  the  sebaceous 
matter — 

R.     Liquor  potassse, f.^j 

Aquae  destil., f ^j.  M. 

SiG. — Applied  to  the  acne  spots  only. 

After  which  they  were  anointed  with — 

R.     Plumbi  nitrat., gr.  xv 

Ung.  petrolei, ^j.  M. 

SiG. — Apply  twice  daily. 

Dr.  Duhring  recommends  the  use  of  the  following,  after  washing 
the  parts  with  hot  water  : — 

R.     Sulphuris  praecip., 3J 

Glycerini, ^S^s 

Adipis  benz  , §  j 

01.  rosae, gtt.  iij.  M. 

Ft.  ung. 

SiG. — To  be  thoroughly  rubbed  into  the  skin  at  night. 


ACNE  ROSACEA. 

Synonyms.     Gutta  rosea  ;  gutta  rosacea. 

Definition.  A  chronic  hyperaemia  or  inflammatory  affection  of 
the  nose  and  cheeks ;  characterized  by  redness,  hypertrophy  of  the 
skin  and  dilatation  and  enlargement  of  the  blood  vessels  supplying 
the  part,  and  the  development  of  more  or  less  acne.  The  nose  and 
cheeks  are  the  most  frequent  location. 

Causes.  Not  always  determined.  It  occurs  in  young  women 
about  puberty  who  are  anaemic,  or  suffer  from  a  general  debility, 
nervous  irritability  or  prostration,  dyspepsia  or  menstrual  irregulari- 
ties. It  often  appears  during  the  menopause.  In  young  males  the 
affection  can  often  be  traced  to  nervous  or  general  debility,  or  dys- 
pepsia. The  use  of  spirituous  liquors  or  of  large  amounts  of  condi- 
ments are  frequent  causes,  as  is  constant  exposure  to  the  weather. 
It  is  frequently  associated  with  seborrhoea. 


416  PRACTICE   OF   MEDICINE. 

Pathology.  There  first  occurs  blood  stasis  in  the  vessels  of  the 
part,  producing  the  undue  redness  first  noticed.  As  a  result  of  the 
stasis,  sooner  or  later  the  capillaries  are  dilated  and  hypertrophied,  and 
as  a  result  of  the  interrupted  circulation  inflammation  of  the  sebaceous 
gland  (acne)  results,  with  the  development  of  papules  and  pustules. 
This  constitutes  the  typical  acne  rosacea.  The  affection  may  proceed 
no  further,  remaining  at  this  point  for  years,  or,  rarely,  the  pathology 
of  this  stage  is  exaggerated,  the  involved  tissues  all  hypertrophying, 
and  the  connective  tissue  undergoing  a  true  hyperplasia,  causing 
increased  size  and  abnormal  shape  of  the  nose. 

Symptoms.  The  onset  of  the  affection  is  slow  and  insidious, 
characterized  at  first  by  more  or  less  diffused  redjiess  of  the  part,  the 
color  aggravated  by  water  or  cold  air.  If  the  nose  be  the  part 
attacked,  it  is  usually  greasy  (seborrhoeic),  and  is  apt  to  be  cool  or  even 
cold.  This  condition  may  remain  for  years,  but  sooner  or  later  the 
evidence  of  dilatation  and  hypertrophy  of  the  capillaries  is  apparent 
by  the  more  decided  and  permanent  redness,  and  upon  close  exami- 
nation the  enlarged  minute  cutaneous  blood  vessels  are  seen  as  deli.- 
cate  or  coarse  red  lines,  running  superficially  over  the  skin  in  an 
irregular  and  tortuous  course.  Soon  are  developed  upon  the  hypersemic 
and  hypertrophied  skin  papules  (acne  papulosa)  and  pustules  (acne 
pustulosa),  their  number  never,  however,  being  very  great.  This 
constitutes  true  acne  rosacea.  The  disease  may  remain  in  this  state, 
or,  rarely,  the  cutaneous  tissues  are  greatly  hypertrophied,  the  blood 
vessels  enormously  dilated,  the  glands  enlarged  and  the  connective 
tissue  undergoes  hyperplasia,  resulting  in  permanent,  dark  red,  bulky 
formations,  the  shape  of  the  nose  being  contorted  into  various  irregular 
forms.  Duhring  reports  a  case  in  which  the  nose  was  the  size  of  the 
patient's  fist  (rhinophyma). 

The  nose  and  cheeks  are  the  usual  location  of  the  disease,  although 
rarely  it  involves  the  forehead. 

Diagnosis.  The  characteristics  of  the  disease  are  so  marked, 
consistmg  of  rosacea — the  dilated  and  hypertrophic  blood  vessels — 
with  papular  and  pustular  acne  superadded,  that  an  error  can  hardly 
occur,  if  due  care  be  exercised. 

Lupus  vulgaris  bears  some  resemblance  to  acne  rosacea,  as  it  is 
apt  to  develop  about  the  face,  and  especially  the  nose  ;  but  the  papules, 
tubercles  and  pustules  of  lupus  vulgaris  soon  ulcerate,  followed  by 
crusts  and  cicatrices,  which  never  occur  in  acne  rosacea. 


DISEASES   OF   THE  SKIN.  4l7 

Lupus  erythematosus  may  be  confounded  with  acne  rosacea  if  it 
occurs  upon  the  end  of  the  nose ;  but  in  the  former  the  skin  is  harsh 
and  covered  with  adherent  whitish  and  yellowish  scales  connected 
with  the  openings  of  the  sebaceous  follicles,  which  is  never  the  case 
in  acne  rosacea. 

Frostbite  resembles  the  first  stage  of  acne  rosacea,  but  the  history 
of  the  two  conditions  soon  determines  the  diagnosis. 

Prognosis.  Favorable,  if  treatment  be  instituted  during  the  first 
stage.    After  hypertrophy  has  occurred  but  little  can  be  accomplished. 

Treatment.  The  cause  is  to  be  sought  after  and  removed,  and 
the  general  health  to  be  promoted.  The  use  of  all  alcoholic  drinks 
is  to  be  interdicted  and  but  small  amounts  of  tea  and  coffee  are  to 
be  allowed.  In  the  first  stage  good  results  may  be  obtained  from  the 
following  formula,  known  as  "  Kummerfeld's  lotion  :  " — 

R.     Sulphur  praecipitat., ^^iv 

Pulv,  camphorae, gr.  x 

Pulv.  tragacanthae, ^^j 

Aquae  calcis,      f  5ij 

Aquae  rosse, f^ij-  M. 

SiG. — Shake  the  bottle  before  using  and  apply  every  few  hours. 
Or— 

R .     Hydrargyri  chlor.  corrosiv., gr.  ij 

Ung.  petrolei, ^j.  M. 

SiG. — Apply  thoroughly. 

Or,  the  following,  suggested  by  G.  H.  Fox — 

^.     Chrysarobini,     / ?ss 

Collodii, gj.  M. 

SiG. — Put  a  brush  through  the  cork  and  paint  lesion  every  evening. 

For  the  second  stage  stronger  applications  are  usually  required. 
The  dilated  capillaries  should  be  incised  with  a  sharp  knife,  in  the 
hope  that  adhesive  inflammation  may  close  the  calibre  of  the  vessels, 
cold  water  compresses  being  used  to  control  the  bleeding,  a  few  of 
the  dilated  vessels  being  thus  treated  every  day  or  two,  until  all  have 
been  incised.  Another  plan  is  to  paint  the  affected  parts,  once  or 
twice  a  week,  with  a  ten  to  twenty  grain  solution  of  pofassa,  following 
its  application  with  an  emollient  poultice.  Electrolysis  has  also  been 
recommended. 

In  the  third  stage  the  knife  is  the  only  effectual  remedy. 
35 


418  PRACTICE   OF   MEDICINE. 

PSORIASIS. 

Synonyms.     Lepra  ;  alphos  ;  psora  ;  English  leprosy. 

Definition.  A  chronic  affection  of  the  skin,  characterized  by 
reddish,  more  or  less  thickened  and  elevated,  dry,  inflammatory  and 
somewhat  wrinkled  patches,  variable  as  to  size,  shape  and  number, 
and  covered  with  abundant  whitish  or  grayish-colored,  imbricated 
scales.     It  is  not  contagious. 

Cause.  Not  known.  The  source  of  the  affection  is,  no  doubt, 
limited  to  the  skin  itself,  as  no  external  or  internal  factors  can  produce 
it.  It  occurs  in  the  robust  and  in  the  feeble,  and  in  males  and  females. 
It  usually  first  appears  in  early  life,  and  recurs  at  intervals  for  years. 

Pathology.  According  to  Dr.  A.  R.  Robinson,  of  New  York, 
"  the  disease  is  essentially  a  hyperplasia  of  the  normal  constituents 
of  the  Malpighian  layer  (mucous  layer).  The  increase  takes  place 
chiefly  in  the  interpapillary  portion  of  the  layer,  the  growth  of  which 
downward  causes  an  apparent  increase  in  the  size  of  the  papillae  of 
the  corium,  which,  however,  on  closer  examination,  are  found  not  to 
be  enlarged.  In  the  later  stages  of  the  disease  the  more  superficial 
blood  vessels  of  the  corium  become  dilated,  a  more  or  less  consider- 
able emigration  of  the  white  blood  corpuscles  takes  place,  and  the 
immediate  neighborhood  of  the  vessels,  together  with  the  connective 
tissue  of  the  corium,  becomes  the  seat  of  a  round-cell  infiltration, 
which,  with  the  effusion  of  serum,  separates  the  connective-tissue 
bundles  and  fibres  into  an  open  mesh  work.  During  the  period  of 
disappearance  of  the  disease  there  is  a  gradual  return  to  the  normal 
condition,  until  the  hyperplasia,  dilatation  of  the  blood  vessels,  and 
cell  infiltration  have  completely  disappeared.  The  hair  in  psoriasis  is 
affected  from  the  beginning  of  the  disease,  hyperplasia  of  the  external 
root  sheath,  the  structure  corresponding  to  the  Malphigian  layer  of  the 
epidermis,  taking  place,  with  extension  of  the  hyperplastic  structure 
into  the  surrounding  cutis.  The  sebaceous  and  sweat  glands  are  not 
at  any  time  affected." 

Symptoms.  Psoriasis  begins  as  small,  reddish  spots,  of  the  size 
of  a  pin's  head,  which  immediately  become  covered  with  scanty  or 
abundant  whitish  ox  grayish,  imbricated  scales.  The  spots  gradually 
increase  in  diameter,  forming  patches  of  various  sizes  and  shapes. 

If  one  of  the  scales  be  detached  by  means  of  the  finger  nail,  it  will 
be  found  to  adhere  quite  firmly  to  the  skin,  and  to  be  about  the  thick- 


DISEASES   OF   THE  SKIN.  419 

ness  of  a  card-board.  If  the  reddish  patch  thus  made  bare  be  pinched 
up  between  the  finger  and  thumb,  and  compared  with  a  similar  pinch 
of  the  healthy  skin,  its  inflammatory  thickening  will  be  discerned. 
There  is  no  watery  discharge  at  atiy  time. 

The  skin  between  the  patches  is  perfectly  healthy. 

While  the  anatomical  lesions  are  always  identical,  the  eruption 
assumes  such  features,  as  to  the  size  and  shape  of  the  patches,  as  to 
give  rise  to  special  names. 

Psoriasis  punctata.  The  eruption  occurs  as  small,  rounded  patches, 
about  the  size  of  a  pin's  head.  This  is  a  rare  variety,  as  the  lesion 
rapidly  increases  in  size. 

Psoriasis  guttata.  The  eruption  occurs  in  the  form  and  size  of 
drops,  and  when  covered  with  scales  gives  the  skin  the  appearance 
of  having  been  splashed  with  mortar,     A  quite  frequent  variety. 

Psoriasis  mummularis.  The  eruption  resembles  variously- sized 
coins.     This  is  frequently  as  large  as  the  patches  grow. 

Psoriasis  circinata.  The  eruption  about  the  size  of  the  former 
variety,  the  centre  clearing  away,  leaving  the  skin  normal,  although 
it  may  continue  to  enlarge  at  the  periphery,  after  the  manner  of  tinea 
circinata. 

Psoriasis  gyrata.  The  eruption  in  wavy  lines,  of  the  width  of  about 
half  an  inch,  resembling  circles  and  semicircles.  This  variety  is  a 
continuation  of  the  former,  from  the  joining  of  the  patches  of  psoriasis 
circinata. 

Psoriasis  diffusa.  The  patches  of  eruption  are  large  and  of  irregu- 
lar shape,  covering  a  considerable  amount  of  surface.  This  variety 
occurs  more  frequently  on  the  front  of  the  leg  and  the  outer  aspect  of 
the  forearm. 

Psoriasis  palmaris  et  plantar  is.  In  these  regions  the  eruption  is 
characterized  by  larger,  thicker  and  less  lustreless  scales,  and  by  the 
occurrence  of  deep  and  painful  fissures,  from  which  exudes  either  a 
serous  or  sanguineous  fluid. 

Psoriasis  U7igiduin.  In  psoriasis  of  the  nails  they  become  thick- 
ened, opaque,  grayish  in  color,  deeply  grooved  transversely  and 
often  pitted,  and  in  'rare  cases  the  nails  are  replaced  by  a  scaly 
incrustation. 

Any  portion  of  the  body  is  liable  to  be  attacked  with  psoriasis.  The 
only  discomfort  the  patient  suffers  is  the  itching,  which  at  times  is 
very  severe  and  distressing. 


420  PRACTICE   OF   MEDICINE. 

Diagnosis.  A  typical  case  of  psoriasis  presents  no  difficulty  in 
diagnosis.  There  are  a  few  affections,  however,  which  may  be  con- 
founding in  irregular  cases. 

Eczema  squamosum  occurring  upon  the  legs  closely  resembles 
psoriasis,  and  if  the  former  has  been  attended  with  a  very  small 
amount  of  moisture  and  the  latter  has  been  considerably  irritated  by 
scratching,  the  diagnosis  will  be  very  difficult. 

The  papulo-squamous  syphiloderm  and  psoriasis  are  frequently 
mistaken  for  each  other,  the  diagnosis  at  times  being  extremely 
difficult. 

Tinea  circinata  and  psoriasis  circinata  resemble  each  other,  but 
the  patches  of  the  latter  are  less  inflammatory,  red  and  infiltrated, 
and  the  scales  more  abundant  and  larger  than  in  the  former.  Tinea 
circinata  is  usually  the  result  of  contagion,  and  the  scales  contain  a 
fungus. 

Seborrhoea  of  the  scalp  and  psoriasis  of  the  same  region  frequently 
are  difficult  of  diagnosis.  In  the  former  the  scalp  is  paler,  the  scales 
are  finer,  smaller,  more  generally  diffused,  of  a  grayish  or  yellowish 
color,  and  greasy,  sebaceous  character.  Psoriasis  of  the  scalp  is 
in  patches,  which  are  reddish  and  infiltrated,  and  there  are  almost 
always  patches  of  the  disease  on  other  parts  of  the  body. 

Prog"nosis.  An  attack  can  easily  be  removed,  but  it  is  always 
apt  to  return,  so  that  a  permanent  cure  can  never  be  promised. 

Treatment.  Constitutional  and  local  measures  are  both  needed 
in  the  majority  of  attacks  of  psoriasis. 

Constitutional  treatment.  Attention  to  the  general  health,  removing 
all  deleterious  influences,  such  as  dyspepsia,  constipation,  liathiasis, 
malaria,  anaemia  or  catarrhs. 

Among  the  most  valuable  remedies  used  in  the  treatment  of  psoriasis 
is  arsenicum,  given  in  full  doses  for  a  long  period.  It  is  to  be  borne 
in  mind,  however,  that  the  drug  is  contraindicated  in  all  acute  and 
inflammatory  cases.  Chrysarobin,  gr.  yi,  t.  d.,  gradually  increased, 
has  been  suggested,  but  of  its  utility  I  have  had  no  experience. 
Phosphorus,  acidum  carbolicum  and  pix  liquida  have  all  been  used 
with  variable  success. 

Local  treatment.  The  character  of  the  local  measures  should  be 
controlled  by  the  duration  of  the  disease,  its  extent,  location  and 
obstinacy. 

The  first  step  is  the  thorough  removal  of  the  scales.     This  may  be 


DISEASES   OF  THE  SKIN.  421 

accomplished  by  repeated  washings  with  soft  soap  and  water,  by  either 
plain  or  alkaline  baths,  medicated  washes  or  caustic  ointments. 

In  the  early  stage,  with  highly  inflammatory  symptoms,  soothing 
applications,  such  as  water  dressings  or  inunctions  with  oils,  of  which 
oleum  olivcB  rubbed  over  the  patch  several  times  each  day  is  very 
serviceable. 

For  chronic  cases  nothing  seems  comparable  with  the  following 
formula,  suggested  by  Dr.  G.  H.  Fox: — 

R.     Chrysarobin, gr.  x-xx-^j 

^theris  et  alcoholis,      ,    .    .    .ad q.  s. 

Collodii, %].  M. 

SiG. — Rub  the  chrysarobin  with  a  little  alcohol  and  ether  and  add  to 
the  collodion. 

If  a  camel's-hair  pencil  be  placed  through  the  cork,  this  may  be 
painted  over  the  affected  patch  after  the  removal  of  the  scales,  and 
after  drying  it  will  not  stain  the  clothing.  Care  must  be  exercised 
that  the  strength  be  not  too  great,  or  a  dermatitis  may  result. 

Other  local  remedies  are  :  pix  liquida,  saponis  viridis,  creasotwn, 
stdphur,  calcium  sulphuretum  and  acidum  carbolicum. 


HYPERTROPHIES  OF  THE  SKIN. 

LENTIGO. 

Synonym.    Freckles. 

Definition.  A  pigmentary  deposit  of  the  skin,  characterized  by 
irregularly- shaped,  pin-head  or  pea-sized,  yellowish,  brownish  or 
blackish  spots,  occurring  for  the  most  part  about  the  face  and  back 
of  the  hands. 

Cause.  In  the  majority  of  instances  exposure  to  the  sun  is  the 
exciting  cause. 

Pathology.  In  anatomical  structure  freckles  consist  of  a  circum- 
scribed, increased  amount  of  normal  pigment,  differing  from  chloasma 
only  in  the  peculiar  form  and  size  of  the  deposit. 

Symptoms.  The  number  of  "  freckles  "  varies  from  a  very  few 
to  immense  numbers.  They  occur  as  brownish  or  yellowish-brown, 
small,  roundish,  irregular  spots,  most  commonly  upon  the  face  and 
hands.  Rarely  the  number  is  very  great,  and  they  give  to  the  skin 
an  uncleanly  appearance.  They  are  apt  to  occur  at  all  ages,  but 
rarely  before  the  third  year. 


422  PRACTICE   OF   MEDICINE. 

They  are  unattended  with  itching  or  other  subjective  symptoms. 

Prognosis.  Usually  favorable.  Their  course,  when  left  to  them- 
selves, is  chronic,  lasting  for  years  or  a  lifetime.  They  ordinarily 
appear  in  the  summer,  fading  away  as  cold  weather  approaches,  to 
return  the  following  summer. 

Treatment.  The  following  application  has  been  usually  success- 
ful in  my  hands  : — 

li  .     Hydrargyri  chlor.  corrosiv.,     .......   gr.  iij 

Acid,  hydrochlorici  dil., f  zj 

Alcoholis, f  5j 

Glyccrini, ^%^^ 

Aquae  rosse, ad f  ^  iv.  M. 

SiG. — Apply   at   bedtime,   and   remove   with   soap  and    water  in  the 
morning. 


CHLOASMA. 

Synonyms.     Liver  spots  ;  moth. 

Definition.  A  pigmentary  discoloration  of  the  skin,  characterized 
by  variously-sized  and  shaped,  more  or  less  defined,  smooth  patches, 
or  of  a  discoloration,  yellowish,  brownish  or  blackish  in  color. 

Cause.  The  etiology  of  chloasma  depends  upon  whether  the 
pigmentation  is  idiopathic  or  symptomatic  in  its  occurrence. 

Idiopathic  chloasma  results  from  the  irritation  of  long-continued 
scratching,  such  as  is  practiced  in  severe  eczema  or  pediculosis,  the 
application  of  blisters  and  sinapisms,  heat,  the  direct  rays  of  the  sun, 
and  various  medicinal  and  chemical  substances,  such  as  follows  the 
prolonged  use  of  argentum  (argyria). 

Symptomatic  chloasma  occurs  in  connection  with  cancer,  malaria, 
tuberculosis,  disease  of  the  supra  renal  capsule  (Addison's  disease), 
disease  of  the  womb,  pregnancy  (chloasma  uterinum),  neurotic  dis- 
turbances, ansemia  and  chlorosis. 

Pathology.  The  affection  is  an  increased  deposit  of  the  normal 
pigment,  having  its  seat  in  the  mucous  layer  of  the  epidermis.  The 
deposition  of  the  pigment  is  the  result  of  a  nervous  derangement, 
possibly  of  the  trophic  system. 

Symptoms.  Chloasma  is  simply  a  discoloration  of  the  skin,  un- 
attended with  alteration  of  the  surface. 

The  patches  vary  in  size  and  shape ;  they  may  be  as  minute  as  a 
coin  or  as  large  as  the  hand,  or  much  larger,  even  to  a  universal 


DISEASES   OF  THE  SKIN.  423 

discoloration  of  the  entire  surface,  and  they  may  be  roundish  or 
irregular  in  outline. 

The  usual  color  is  yellowish,  brownish  or  muddy,  or  even  blackish 
{melas7na,  tnelano derma) . 

In  Addison  s  Disease,  of  a  typical  character,  "  the  coloration  is 
brownish,  with  an  olive-greenish  or  bronze  tint,  and  is  general, 
although  as  a  rule,  especially  pronounced  upon  regions  having  a 
disposition  to  normal  increase  of  pigment,  as  the  face,  backs  of  the 
hands,  axillas,  areolae  of  the  nipples,  and  the  genital  organs ;  the  hair, 
also,  may  become  darkened.  It  may.  also,  occur  with  or  follow  other 
pigmentary  changes,  as  of  the  hair.  Gaskoin  reports  a  case,  occurring 
in  a  woman  aged  forty-five,  where  the  patch,  situated  on  the  cheek, 
near  the  nose,  was  intensely  dark.  It  had  existed  nine  years.  The 
color  of  the  hair  had,  fifteen  years  previously,  changed  from  carroty- 
red  to  black."     For  additional  symptoms,  see  page  367. 

In  Argyria,  or  discoloration  of  the  skin  resulting  from  the  internal 
use  of  nitrate  of  silver,  the  color  is  a  bluish,  bluish-gray,  slate,  bronze 
or  blackish,  varying  as  to  the  shade.  It  occurs  over  the  surface 
generally,  but  is  more  pronounced  upon  parts  exposed,  as  the  face 
and  hands. 

Chloasma  uteritium  occurs  most  frequently  between  the  ages  of 
twenty-five  and  fifty,  seldom  after  the  menopause,  caused,  in  the 
greater  number  of  instances,  by  changes,  physiological  and  patho- 
logical, which  take  place  in  connection  with  the  uterus.  It  is  seen 
in  the  married  and  single,  although  much  commoner  in  the  former. 
Pregnancy  is  the  most  frequent  cause,  although  also  associated  with 
either  dysmenorrhcea,  chlorosis,  anaemia  or  hysteria. 

It  is  seen  in  the  mildest  degree  about  the  eyelids,  especially  during 
the  menstrual  epoch,  as  a  duskiness  or  swarthiness  of  the  complexion, 
either  lasting  a  few  days  or  being  permanent.  As  usually  encoun- 
tered, however,  chloasma  of  this  variety  consists  in  the  presence  of 
one  or  several  patches,  appearing  generally  about  the  forehead  or 
other  parts  of  the  face,  upon  the  trunk,  about  the  nipples  and  upon 
the  abdomen.  Rarely  the  entire  face  is' covered  with  a  discoloration, 
resembling  a  mask.  Cases  are  recorded  in  which  the  pigmentary 
deposit  was  general,  resembling  Addison's  disease. 

Diagnosis.  Tinea  versicolor  and  chloasma  resemble  each  other 
in  the  color  of  the  patches,  but  otherwise  they  have  nothing  in  com- 


424  PRACTICE   OF   MEDICINE. 

mon.  Tinea  versicolor  occurs  on  the  trunk,  while  chloasma  occurs 
upon  the  face  and  about  the  nipples,  and  in  cases  the  result  of  preg- 
nancy about  the  umbilicus,  except  in  those  comparatively  rare 
instances  in  which  the  discoloration  is  diffused.  The  patches  of 
chloasma  are  smooth,  those  of  tinea  versicolor  furfuraceous,  as  can 
readily  be  demonstrated  by  gently  scraping  the  discoloration  with  the 
finger  nail. 

Prognosis.  Unless  the  result  of  Addison's  disease,  the  prolonged 
use  of  argentum,  tuberculosis  or  cancer,  favorable. 

Treatment.  Chloasma,  not  the  result  of  organic  disease,  or  the 
use  of  argentum,  is  usually  removed  by  either  of  the  following 
formulae : — 

R  .     Hydrargyri  chloridi  corrosiv., gr.  viiss 

Zinci  sulphat., ^ss 

Plumbi  acetatis, ;5  ss 

Aquoe, f.^  iv-  M* 

SiG. — Lotion.     Apply  morning  and  evening. 

— Hardy. 


Or— 


R  .     Hydrargyri  chloridi  corrosiv., gr-  vj 

Acidi  acetici  dil., f^ij 

Boracis, h^ij 

Aquae  rosae, f  ^  iv.  M. 

SiG. — Lotion.     Apply  twice  daily. 

— BULKLEY. 


Or- 


R.     Hydrarg.  ammoniat., ^} 

Bismuthi  subnit., Z] 

Ung.  petrolei., 5J.  M. 

SiG. — Apply  frequently. 

For  argyria,  the  first  step  is  the  withdrawal  of  the  argentum,  and, 
according  to  Prof.  Bartholow,  "  a  persistent  and  long-continued  use 
o{  potassii  iodidum  and  sodii  hypophosphis  has,  in  a  few  fortunate 
instances,  caused  the  absorption  and  excretion  of  the  silver  deposits. 
The  action  of  these  systemic  remedies  for  the  discoloration  may  be 
aided  by  baths  of  the  hyposulphites,  and  by  the  cautious  use  of  lotions 
containing  potassii  cyanidum,  which  possesses  a  decided  solvent 
power  over  the  silver  deposits." 


DISEASES   OF  THE  SKIN.  425 


CALLOSITAS. 


SynonyrQS.     Tyloma  ;  callus  ;  callosity. 

Definition.  Callositas  or  tyloma  consists  in  the  development  of 
a  hard  or  horny,  thickened  patch  of  skin,  variable  in  extent,  and  of 
a  grayish,  yellowish  or  brownish  color,  and  unattended  with  pain. 
The  most  frequent  location  is  upon  the  hands  and  feet. 

Causes.  The  result  of  pressure  or  friction,  as  in  the  case  of 
the  hands  of  the  mechanic,  the  effect  of  his  tools  ;  or,  if  upon  the 
foot,  the  result  of  ill-fitting  shoes  or  from  unusual  walking.  Cal- 
losities are  also  seen  upon  the  fingers  of  violin,  banjo  and  harp 
players. 

Pathology.  A  hypertrophy  of  the  horny  layer  of  the  skin,  the 
corium  remaining  normal.  The  cells  of  the  epidermis  become  so 
closely  packed  together  as  often  to  simulate  horn  substance. 

Symptoms.  Callositas  consists  in  an  increase  in  the  thickness 
of  the  skin  of  the  affected  part,  presenting  a  firm,  dense,  more  or 
less  circumscribed  structure,  the  extent  of  hardness  varying  consid- 
erably, sometimes  being  horny.  The  patch  of  hardness  is  generally 
about  the  size  of  a  coin,  roundish  in  shape  and  somewhat  elevated 
above  the  surrounding  skin.  The  color  of  the  patch  may  be  either 
grayish,  yellowish  or  brownish. 

Callosities  are  usually  upon  the  palms,  fingers,  soles  and  toes, 
although  other  parts,  if  exposed  to  the  cause,  may  also  be  the  seat. 
At  times  great  pain  and  discomfort  are  experienced  from  the 
growth. 

Occasionally  callosities  are  complicated  by  hyperasmia,  fissure,  acute 
inflammation,  abscess,  erysipelas,  and  serve  readily  as  foci  for  such 
cutaneous  diseases  as  eczema  and  psoriasis. 

Course.  Their  formation  and  development  is  always  slow  and 
gradual.     If  the  cause  be  removed,  the  prognosis  is  favorable. 

Treatment.  If  the  removal  of  the  callous  growth  be  desirable, 
the  part  should  be  repeatedly  soaked  in  warm  water,  or  a  poultice 
applied,  or  warmed  oil  kept  in  contact  by  compresses  of  flannel, 
which  will  soften  the  induration  and  permit  its  removal  by  paring 
or  scaping,  layer  by  layer,  with  a  sharp  knife.  Success  has  been 
reported  from  the  use  of  a  plaster  of  india-rubber  containing  acidum 
salicylicum. 


426  PRACTICE   OF   MEDICINE. 

CLAVUS. 

Synonym.     Corn. 

Definition.  A  corn  is  a  small,  circumscribed,  usually  flat,  deep- 
seated  hypertrophy  of  the  epidermis,  having  a  horny  feel,  projecting 
slightly  from  the  skin,  painful  upon  pressure,  situated,  for  the  most 
part,  about  the  toes. 

Cause.  Continued  pressure  or  friction,  usually  from  ill-fitting  or 
tight  boots  or  shoes. 

Pathology.  A  clavus  consists  of  a  circumscribed,  excessive 
hypertrophy  of  the  epidermis,  of  the  same  character  as  occurs  in 
callosity,  and  of  a  central  portion — the  core.  The  core  extends  deeply 
into  the  tissues,  in  the  shape  of  an  inverted  cone,  the  base  of  the  cone 
being  directed  outward  and  appearing  upon  the  surface  as  a  roundish 
elevation,  its  apex  resting  upon  the  papillary  layer  of  the  corium. 
The  core  of  a  clavus  consists  of  a  whitish,  opaque,  firm,  tenacious 
body,  composed  of  epidermic  cells,  arranged  in  concentric  laminae. 

The  pain  attending  the  presence  of  corns  results  from  pressure 
upon  the  true  skin  by  the  hard  core,  causing  irritation  of  the  nerve 
filaments  of  the  papillae. 

Corns  existing  between  two  toes  are  constantly  bathed  with  the 
moisture  of  the  part,  which  macerates  and  softens  the  formation, 
which  thus  receives  the  name  of  soft  corn,  in  contradistinction  to  the 
hard  corn. 

Symptoms.  Until  the  growth  attains  a  considerable  size  no  dis- 
comfort, as  a  rule,  is  felt.  After,  however,  its  depth  has  reached  the 
true  '^\i\xi,pain  of  an  intermittent  character,  aggravated  by  pressure, 
is  the  chief  symptom. 

Corns  are  often  weather-sensitive,  being  unusually  painful  before, 
during  or  after  the  occurrence  of  storms,  and  should,  therefore,  not 
be  confounded  with  gouty  or  rheumatic  deposits  below  the  skin. 

Treatment.  If  freedom  from  these  annoying  formations  be 
desired,  the  use  of  a  properly  fitting  foot-covering  must  be  practiced, 
The  pressure  which  results  in  the  severe  pain  is  limited  by  the  use  of 
the  ringed  protective  plasters  in  common  use. 

To  remove  the  corn,  soaking  with  hot  water,  or  a  poultice  kept  in 
contact  over  night,  will  soften  the  part  and  permit  of  its  ready  removal 
with  the  knife. 


DISEASES   OF  THE  SKIN.  427 

For  soft  corns,  the  application  of  argenti  nitras,  in  solid  stick  form , 
is  highly  spoken  of,  to  be  used  after  the  growth  has  been  sufficiently- 
softened. 

VERRUCA. 

Synonym.    Wart. 

Definition.  A  wart  consists  of  a  circumscribed  hypertrophy  of 
the  papillary  layer,  with  more  or  less  epidermal  accumulation,  char- 
acterized by  the  appearance  of  a  hard  or  soft,  rounded,  flat  or  acumi- 
nated formation,  of  variable  size. 

Varieties.  The  following  varieties  have  chiefly  a  descriptive 
value:  verruca  vulgaris ;  verruca  plana ;  verruca filiformis ;  verruca 
digitata;  verruca  acuminata. 

Cause.  Obscure.  The  various  assigned  causes  are  probably 
incapable  of  producing  the  affection. 

Pathology.  While  the  anatomy  of  warts  differs  somewhat  accord  - 
ing  to  their  variety,  in  all  forms  there  exist  as  a  basis  of  their  forma  - 
tion  a  connective-tissue  growth,  from  which  the  papillary  hypertrophy 
takes  place.  The  interior  of  the  growth  is  supplied  by  one  or  more 
vascular  loops,  from  which  their  vitality  is  obtained . 

Symptoms.  The  various  forms  are  so  different  as  to  require  a 
separate  description. 

Verruca  vulgaris,  or  the  ordinary  wart,  commonly  seen  on  the 
hands,  consists  of  a  small,  circumscribed,  elevated  growth,  having  a 
broad  base  seated  securely  upon  the  skin.  Their  consistency  is  either 
soft  or  firm,  the  surface  smooth  or  rough,  the  color  that  of  the  sur- 
rounding skin,  or  yellowish,  brownish  or  even  blackish. 

They  may  develop  upon  any  region  of  the  body,  but  are  most 
commonly  seen  upon  the  hands  and  fingers. 

Verruca  plaiia  differs  from  the  vulgaris  in  being  flat  and  broad  in 
form,  and  but  slightly  raised  above  the  level  of  the  surrounding  skin. 

Their  most  common  location  is  either  on  the  back  or  forehead. 

Verruca  filiformis  assumes  the  shape  of  a  minute,  thin,  conical  or 
thread-like  formation,  about  an  eighth  of  an  inch  in  length. 

The  most  frequent  location  is  the  face,  eyelids  and  neck. 

Verruca  digitata  consists  of  a  slightly  elevated,  broad  formation, 
about  the  size  of  a  split  pea,  and  marked  by  a  number  of  digitations 
coming  from  its  border,  giving  an  appearance,  in  marked  cases, 
resembling  a  crab. 


428  PRACTICE   OF   MEDICINE. 

Their  most  frequent  site  is  upon  the  scalp. 

Verruca  acuminata,  known,  also,  as  the  pointed  wart,  the  moist 
wart,  the  pointed  condyloma,  cauliflower  excrescence  and  venereal 
wart,  consists  of  one  or  more  groups  of  irregularly-shaped  elevations, 
often  so  closely  packed  together  as  to  form  a  more  or  less  solid  mass 
of  vegetations  (verrucae  vegetantes).  Their  color  depends  somewhat 
upon  the  degree  of  vascularity,  varying  from  a  pinkish,  bright  red  to 
a  purple  color. 

They  occur,  for  the  most  part,  about  the  genitalia  of  either  sex. 
Upon  the  penis,  they  usually  spring  from  the  glans  and  the  inner 
surface  of  the  prepuce  ;  the  inner  surface  of  the  labia  and  from  the 
vagina  in  the  female.  They  are  also  seen  about  the  anus,  mouth, 
axillae,  umbilicus  and  toes.  They  may  be  either  moist  or  dry, 
according  to  their  location  ;  about  the  genitalia,  a  yellowish,  puriform 
secretion  usually  covers  their  surface,  due  to  friction  and  maceration, 
which,  owing  to  the  heat  of  the  parts,  rapidly  decomposes,  producing 
a  highly  offensive,  penetrating  and  disgusting  odor. 

Their  size  varies  from  that  of  a  pea  to  that  of  an  almond,  an  t.g%, 
or  even  the  fist.  Their  development  is  rapid,  attaining  considerable 
size  in  a  few  weeks. 

Prognosis.     Favorable. 

Treatment.  For  the  smaller  warts,  excision  by  means  of  the 
knife  or  scissors  affords  the  most  satisfactory  results.  If  the  growth 
be  large  and  likely  to  be  attended  with  considerable  hemorrhage, 
as  in  cases  of  the  condyloma  about  the  genitalia,  the  galvano-caustic 
wire  or  the  Paquelin  cautery  are  to  be  preferred.  Transfixing  the 
growth  in  several  directions  with  long  needles  dipped  in  a  fifty  per 
cent,  solution  of  aciduni  chrc7nicu7n  has  been  recommended.  The 
topical  application  of  caustics,  such  as  acidimi  aceticum,  acidum 
nitricutn,  argenti  nitras  or  ferri  perchloriduin  are  often  satisfactory. 
I  have  been  successful  in  some  cases  by  painting  the  growth  with 
tinctura  thuja  occidentalis  until  their  size  was  considerably  reduced, 
and  then  snipping  them  off  with  the  scissors.  The  following  formula 
for  warts  and  corns  is  generally  sold  by  pharmacists : — 

R .     Acidi  salicylic!, ,:5  ss 

Ext.  cannab.  indica*, ^r.  v-x 

CoUodii, 5  ss-j.  M. 

SiG. — Apply  once  or  twice  daily. 


DISEASES   OF   THE   SKIN.  429 

An  excellent  formula  is  : — 

U .     Acidi  salicylici, 

Acidi  boracici, aa gr.  xv 

Hydrargyri  chlor.  mite, gr-  x.  M. 

SiG. — Sprinkle  over  twice  dail  y. 

ICHTHYOSIS. 

S3nionyins.     Ichthyosis  vera  ;  fish-skin  disease. 

Definition.  Ichthyosis  is  a  congenital,  chronic  deformity  or  hyper- 
trophic disease  of  the  skin,  characterized  by  dryness,  harshness  or 
general  scaliness  of  the  skin,  or  in  the  outgrowth  of  larger  masses  of 
a  corneous  consistency. 

Varieties.     Ichthyosis  simplex  ;  ichthyosis  hystrix. 
Cause.     Often    hereditary,   but   not  in   all   cases.      It   is  to  be 
regarded  as  an  affection  which  is  born  with  the  individual,  although 
it  does  not  usually  manifest  itself  until  after  the  first  or  second  year 
of  life. 

Pathology.  "  The  diseased,  or,  better,  deformed  skin  is  found 
microscopically  to  be  hypertrophied  in  various  degrees,  according  to 
the  development  of  the  malady ;  the  proliferation  of  its  elements 
occurring  in  the  connective  tissue,  papillae,  stratum  corneum  and 
blood  vessels.  In  well-marked  cases  of  ichthyosis  hystrix,  the 
elongated  papillae  are  surmounted  by  dense  cones  of  the  horny  layer 
of  the  epidermis,  more  or  less  concentrically  disposed,  with  sclerosis 
of  the  connective  tissue  and  a  relatively  unchanged  rete.  In  this  last 
particular  the  dense  plaque  of  ichthyosis  differs  in  texture  from  the 
wart."     (Hyde.) 

Symptoms.  Ichthyosis  displays  a  wide  variation  in  its  symptoms. 
In  one  mdividual  it  amounts  to  but  a  slight  inconvenience,  while  in 
another  it  may  manifest  itself  in  so  pronounced  a  manner  as  to  be 
the  source  of  great  discomfort  and  deformity.  The  two  varieties 
named  represent  merely  accentuated  types  of  the  disorder,  rare  in  its 
fullest  development,  and,  in  its  slightest,  much  more  common  than  is 
generally  believed. 

A  simple  dryness  and  harshness  of  the  skin,  with  only  slight  fur- 
furaceous  exfoliation,  is  termed  xeroderma. 

Ichthyosis  simplex  is  the  more  common  variety,  consisting  of  a 
harsh,  dry  condition  of  the  whole  surface,  accompanied  by  the  pro- 


430  PRACTICE   OF   MEDICINE. 

diiction  of  variously  sized  and  shaped  reticulated  scales,  either  small, 
thin  and  furfuraceous,  like  bran,  or  large  and  thick,  resembling  fish 
scales.  Upon  the  extremities  the  scales  usually  form  diamond-shaped 
or  polygonal  plates,  separated  from  one  another  by  furrows  or  lines, 
which  extend  down  to  the  normal  skin.  In  color  the  scales  are  either 
whitish,  grayish  or  yellowish,  and  often  have  a  silvery  or  glistening 
appearance.  Rarely  the  color  is  olive  green  or  blackish  {ichthyosis 
nigricans).  The  amount  of  scaling  depends  upon  the  age  of  the 
patient  and  the  duration  and  severity  of  the  disease. 

Ichthyosis  hystrix.  With  or  without  the  developments  of  the  above 
variety,  in  this,  the  hypertrophy  of  the  skin  may  occur  in  circum- 
scribed patches  or  large  areas,  consisting  of  irregularly-shaped,  ver- 
rucous corneous,  corrugated,  wrinkled  or  rugous  masses,  usually 
darker  in  color  than  those  of  the  simple  variety.  They  may  occur 
upon  the  arms,  as  solid,  warty  patches,  or  upon  the  back,  in  the  form 
of  elongated,  linear  patches.  They  may  constitute  roughened,  corru- 
gated, papillary  growths,  or  uneven,  horny,  blunt  or  pointed,  spinous, 
warty  formations.  In  the  latter  case  the  elevations  may  reach  several 
lines  or  more,  and  stand  out  from  the  skin  like  quills  upon  the  back 
of  a  porcupine — hence  the  name  hystrix.  The  amount  and  extent  of 
the  hypertrophy  varies  ;  the  older  the  patient  the  more  highly  devel- 
oped it  will  usually  be. 

Course.  Ichthyosis  siinplex  may  involve  the  entire  surface  uni- 
formly or  appear  more  marked  on  the  extremities,  from  the  hips  to 
the  ankles  and  the  arms  and  forearms.  The  affection  is  always 
worse  in  winter  than  in  summer,  the  increased  activity  of  the  sweat 
glands  at  this  season  producing  the  most  beneficial  results.  The 
course  of  the  affection  is  essentially  chronic,  continuing  throughout 
life,  now  better,  now  worse.     Slight  itching  usually  occurs. 

Diagnosis.  The  characteristics  of  the  affection  are  so  peculiar 
that  an  error  in  diagnosis  is  hardly  possible.  It  is  to  be  distinguished 
from  the  inflammatory  affections  of  the  skin  which  terminate  in  des- 
quamation by  the  absence  of  any  history  of  inflammation. 

Prognosis.  While  much  can  be  done  to  alleviate  the  affection, 
the  prognosis  is  unfavorable  as  regards  permanent  relief. 

Treatment.  Local  measures  are  alone  of  value  for  ichthyosis. 
The  maceration  of  the  accumulated  masses  of  epithelial  hypertrophy 
is  accomplished  by  water  baths,  either  simple  or  medicated.  The 
relief  thus    afforded   the   patient,   while    temporary,   is  comforting. 


DISEASES   OF  THE   SKIN.  431 

Duhring  says :  "  It  may  be  stated,  then,  that,  as  a  rule,  the  more  fre- 
quemly  the  ichthyotic  patient  bathes,  and  the  longer  he  is  able  to 
remain  in  the  water,  the  less  will  the  deformity  show  itself."  Vapor 
and  alkaline  baths  are  also  serviceable.  Another  valuable  agent  is 
sapo  mollis  in  conjunction  with  baths,  or  alone,  as  a  discutient.  For 
severe  cases,  "  a  sufficient  quantity  is  to  be  rubbed  into  the  skin  twice 
daily,  for  four  or  six  days,  during  which  period  the  patient  is  to  refrain 
from  bathing.  A  bath  is  first  to  be  taken  four  or  five  days  after  the 
last  rubbing,  when,  in  fact,  the  epidermis  has  begun  to  peel  off"; 
afterward  inunction  with  a  simple  ointment  is  to  be  applied,  in  order 
to  prevent  Assuring  of  the  new  skin. 
The  following  is  a  useful  formula : — 

R.     Adipis  benz., ^j 

Glycerini,     ... TT^xl 

Ung.  petrolei, ^ss.  M. 

SiG. — Apply  daily,  after  washing  or  bathing. 

— Duhring. 
Or— 

U  .     Potassii  iodidi, gr.  xx 

Olei  bubuli, 

Adipis, aa, ^ss 

Glycerini, ^j.  M. 

SiG. — Apply  after  bathing. 

— Milton. 


PARASITIC   DISEASES    OF   THE    SKIN. 
TINEA  FAVOSA. 

S3nionyins.     Favus ;  porrigo  favosa ;  honeycombed  ringworm. 

Definition.  A  contagious  affection  of  the  skin,  due  to  a  vegetable 
parasite — Achorion  Schonleinii ;  characterized  by  the  development  of 
either  discrete  or  confluent,  small,  circular,  cup-shaped,  pale  yellow, 
friable  crusts,  usually  perforated  by  hairs. 

Cause.  The  presence  and  growth  of  a  vegetable  parasite  known 
as  the  Achorion  Schonleinii  is  the  cause  of  tinea  favosa.  It  is  com- 
moner in  children  than  in  adults,  attacking  the  former,  in  the  first 
place,  either  de  novo  or  through  direct  contagion,  and  is  from  them 
communicated  to  adults.  It  is  a  disease  confined  almost  exclusively 
to  the  lower  classes.     It  is  rare  in  the  United  States. 

Pathology.    Tinea  favosa  may  have  its  seat  either  in  the  hair 


432  PRACTICE  OF  MEDICINE. 

follicle  and  hair,  or  upon  the  surface  of  the  skin  or  the  nails ;  the 
former,  however,  are  the  structures  most  commonly  attacked. 

It  is  purely  a  local  affection,  due  solely  to  the  presence  and  growth 
of  the  vegetable  parasite  discovered  by  Schonlein,  of  Berlin,  in  1839, 
and  named  after  him — Achorion  Schonleinii.  The  crusts  are  made 
up  almost  entirely  of  fungus,  which  is  seen,  upon  section,  with  the 
naked  eye,  to  be  composed  of  a  porous  mass  and  to  possess  a  pale- 
yellow  or  whitish  color.  Under  the  microscope  it  is  seen  to  consist  of 
both  mycelium  and  spores  in  great  quantity  and  in  all  stages  of 
development. 

Symptoms.  When  the  affection  attacks  the  hairs  and  follicles  it 
is  termed  tinea  favosa  pilaris,  when  the  epidermis,  ti7iea  favosa  epi- 
dermis, and  when  the  nails,  ti7iea  favosa  unguium.  Rarely  all  the 
structures  may  be  attacked  at  one  and  the  same  time ;  its  usual  seat, 
however,  is  the  scalp. 

The  disease  begins  by  the  development  of  one  or  of  several  pin- 
head-sized,  pale-yellow  crusts,  seated  about  the  hair  follicles.  In 
about  a  fortnight  these  crusts  have  increased  in  size  and  are  umbili- 
cated,  termed  \ki^  favus  cups,  are  circumscribed,  circular  in  form  and 
very  slightly  elevated  above  the  level  of  the  skin. 

In  their  normal  condition  they  are  of  a  pale-yellow  or  sulphur- 
yellow  color,  but  after  a  time,  from  dust  and  other  matters,  they 
become  brownish-  or  greenish-yellow  in  color.  The  number  of  crusts 
vary  from  a  very  few  to  immense  numbers.  The  usual  size  is  abo  ut 
that  of  a  split-pea.  In  tinea  favosa  pilaris  et  capitis  the  affection  is 
often  accompanied  with  pediculi,  while  swelling  of  the  glands  of  the 
neck  and  small  abscesses  upon  the  scalp  are  not  uncommon.  The 
hairs  become  lustreless,  opaque,  brittle,  and  at  times  split  longitudi- 
nally, and  from  atrophy  of  the  folUcles  and  sebaceous  glands  perma- 
nent baldness  may  result. 

In  tinea  favosa  unguium  the  nails  become  thickened,  yellow, 
opaque  and  brittle. 

The  disease  has  a  peculiar  odor,  resembling  that  of  mice,  or  of 
musty,  stale  straw. 

Diagnosis.  In  a  recent  case  the  characteristic  favus  cups,  the 
pale-yellow  color,  the  odor  and  the  history  of  contagion  should  ren- 
der the  diagnosis  easy.  If  of  long  standing,  however,  and  the  favi 
destroyed  by  scratching,  some  doubt  may  exist ;  but  if  a  small 
fragment  of  a  crust   be   placed  upon  a  glass   slide  with  a  drop  of 


DISEASES   OF   THE   SKIN.  433 

liquor  potasses,  covered  with  a  thin  glass  and  placed  under  a  micro- 
scope with  a  power  of  from  two  hundred  and  fifty  to  five  hundred 
diameters,  the  features  of  the  Achorion  Schonlemii  will  determine  the 
affection  to  be  tinea  favosa. 

Prognosis.  Tinea  favosa  of  the  epidermis  readily  responds  to 
treatment.  Tinea  favosa  pilaris  is  more  obstinate,  and  if  of  long 
duration  may  result  in  baldness. 

Treatment.  The  general  health,  in  the  majority  of  instances, 
requires  tonics.     Cleanliness  is  essential  to  successful  management. 

For  tinea  favosa  pilaris  et  capitis,  two  remedies  are  essential — 
parasiticides  and  depilation.  The  hair  should  be  cut  as  short  as 
possible,  the  crusts  removed  by  the  use  of  oil,  or  soap  and  hot  water, 
or  poultices,  again  well  oiled  and  the  hairs  removed  by  means  of 
broad-bladed  forceps,  a  few  hairs  being  removed  at  a  time  and  only 
a  small  surface  cleared  at  each  sitting,  when  the  following  lotion  is  to 
be  thoroughly  applied  : — 

R.     Hydrarg.  chlorid.  corrosiv., gr.  v-x 

Ammonii  chlorid.  pur., "T^^s 

Misturae  amygdalse  amar., ^  iv.  M. 

SiG. — Apply  thoroughly. 

— BULKLEY. 

Or— 

R.     Sulphur, 5J 

Hydrarg.  ammoniat., gr.  xx 

Ung.  petrolei, f  ^  j.  M. 

SiG. — Rub  in  well. 

Tinea  favosa  of  non-hairy  parts  requires  the  removal  of  the  crusts 
and  the  application  of  either  of  the  above  formulae. 

TINEA   CIRCINATA. 

Synonyms.  Tinea  trichophytina  corporis  ;  herpes  circinatus  ; 
ringworm  of  the  body. 

Definition.  A  contagious,  parasitic  affection  of  the  skin,  due  to 
the  trichophyton  fungus ;  characterized  by  the  development  of  one 
or  more  circular  or  irregularly  shaped,  variously-sized,  inflammatory, 
slightly  vesicular  or  squamous  patches,  occurring  upon  the  general 
surface  of  the  body. 

Cause.  Ringworm  of  the  body  is  caused  by  the  presence  of  a 
36 


434  PRACTICE   OF   MEDICINE. 

vegetable  parasite  discovered  by  Bazin,  in  1854,  termed  the  tricho- 
phyton, the  same  growth  or  fungus  that  produces  tinea  tonsurans  and 
tinea  sycosis.  The  affection  is  highly  contagious,  and  is  frequently 
communicated  from  one  member  of  a  family  to  another,  although  it 
has  been  determined  that  a  certain  unknown  condition  of  the  skin  is 
requisite  for  its  development.  In  children  it  is  most  frequently  seen 
among  the  weakly  and  poorly  nourished.  In  adults  it  is  usually 
associated  with  a  decline  in  the  general  health. 

Pathology.  The  fungus  is  seated  between  the  strata  of  the 
epidermis,  more  particularly  in  the  superior  layers  of  the  rete.  The 
presence  of  this  foreign  body  produces  the  subsequent  phenomena — 
a  superficial  dermatitis,  erythema,  exudation,  minute  vesiculation  and 
papulation,  and,  in  the  severe  grades,  tubercles  and  pustules.  The 
desquamative  symptoms  are  exfoliative — nature's  efforts  for  relief. 

Symptoms.  Tinea  circinata  varies  greatly  in  the  degree  of  its 
development,  from  the  trivial  complaint  so  often  seen  in  children,  to 
the  chronic,  extensive  and  obstinate  disease  sometimes  seen  about  the 
thighs  in  adults  {tinea  circinata  cruris). 

The  disease  usually  begins  as  a  small,  reddish,  scaly,  rounded  or 
irregularly-shaped  spot  of  papules,  which,  in  a  very  few  days,  assumes 
a  circular  form  (ringworm).  It  continues  to  increase  in  size,  the 
papules  often  changing  to  vesicles.  A  characteristic  of  the  eruption 
is  its  healing  in  the  centre  as  it  spreads  on  the  periphery.  Occasion- 
ally the  circles  or  rings  coalesce,  forming  serpiginous  lesions.  The 
usual  size  of  a  fully  developed  ringworm  is  about  that  of  a  silver 
quarter  of  a  dollar. 

Chronic  tinea  circinata  does  not  present  the  characteristic  annular 
form,  but  "  are  usually  in  the  form  of  single  or  multiple,  disseminated, 
small,  reddish,  slightly  scaly,  ill-defined  spots,  on  a  level  with  or  but 
slightly  raised  above  the  surrounding  skin.  Not  infrequently  they  are 
the  size  of  a  small  or  large  finger  nail,  and  are  irregularly  shaped, 
and,  as  a  rule,  without  line  of  demarcation," 

The  "eczema  marginatum"  of  Hebra  is  to  be  looked  upon  as  a 
severe  form  of  tinea  circinata. 

Tinea  circinata  cruris,  or  ringworm  of  the  thighs,  a  variety  of  the 
"eczema  marginatum  of  Hebra,"  is  usually  complicated  with  true 
eczema,  and  is  a  very  obstinate,  chronic  form  of  the  affection  ;  it  is 
accompanied  by  severe  itching. 

Tinea  trichophytina  unguium  is  a  rare  variety.     The  nails  become 


DISEASES    OF   THE   SKIN.  435 

opaque,  whitish,  thickened  and  soft  and  brittle,  especially  along  their 
free  border.  The  microscope  is  essential  for  a  diagnosis.  Its  course 
is  chronic,  and  it  is  difficult  to  cure. 

Course.  As  commonly  seen,  ringworm  is  very  amenable  to  treat- 
ment. Occasionally,  however,  it  exhibits  great  obstinacy,  showing 
itself  repeatedly  in  the  same  region,  in  the  form  of  relapses,  or  mani- 
festing itself  from  time  to  time  in  new  localities. 

Diag'nosis.  Tinea  circinata  may  be  mistaken  for  squamous  or 
other  varieties  of  eczema,  but  the  circular  and  often  annular  form, 
the  well-defined  margin,  the  slight  desquamation  and  the  course  and 
history  of  ringworm  should  prevent  error.  Chronic  ringworm  is  more 
difficult,  however. 

Seborrhoea  and  psoriasis  often  assume  a  somewhat  circular  form, 
and  then  have  a  resemblance  to  ringworm ;  but  a  study  of  the  clini- 
cal history  should  render  the  diagnosis  easy. 

All  doubtful  points  in  diagnosis  should  be  determined  by  the 
microscope.  The  examination  can  readily  be  made  in  the  following 
manner:  "A  few  of  the  scales  maybe  scraped,  with  a  blunt  knife 
blade,  from  the  suspected  patch  and  placed  upon  a  glass  slide  con- 
taining a  drop  of  liquor  potassas,  over  which  is  laid  a  thin  glass  cover. 
The  cover  should  be  pressed  down  and  the  epidermic  mass  flattened 
out.  Permitting  the  specimen  to  remain  for  a  few  minutes,  it  may  be 
viewed  with  a  power  of  from  two  hundred  and  fifty  to  five  hundred 
diameters.  The  fungus  will,  in  most  cases,  be  detected  here  and 
there,  having  at  first  a  faint  outline,  but  becoming  more  distinct  as  the 
specimen  stands." 

Prognosis.  Favorable,  as  a  rule,  although  the  affection  is  rebel- 
lious to  treatment  in  some  instances,  and  prone  to  relapses. 

Treatment.  Local  treatment  is  usually  all  that  is  required  for 
the  cure  of  tinea  circinata.  In  the  majority  of  instances  the  following 
plan  will  be  successful.  Washing  the  patch  with  soft  soap  and  water 
and  the  apphcation  of  one  of  the  following  ointments  : — 

R .     Cupri  acetat. , gr.  x 

Ung.  aquse  rosse, ^j.  M. 

SiG. — Keep  in  contact  with  the  patch. 

Or— 

R .     Hydrargyri  ammoniat., gr.  xx-xxx 

Ung.  petrolei, Jj.  M. 

SiG. — Keep  in  contact  with  the  patch. 


436  PRACTICE   OF   MEDICINE. 

"  In  obstinate  tinea  circinata  cruris  the  following,  recommended  by 
Tilbury  Fox,  may  be  employed  : — 

R.     Creasoti,      TT\^  xx 

Olei  cadini, f.^iij 

Sulphuris  sublimati, ^iij 

Potassii  bicarb., ^] 

Adipis, ^j.  M. 

SiG. — Keep  in  contact  with  the  affection. 

TINEA  TONSURANS. 

Synonyms.  Tinea  trichophytina  capitis ;  herpes  tonsurans ; 
ringworm  of  the  scalp. 

Definition.  A  contagious,  parasitic  affection  of  the  scalp,  due  to 
the  trichophyton  fungus ;  characterized  by  the  development  of  cir- 
cumscribed, vesicular  or  squamous,  more  or  less  bald  patches,  show- 
ing the  hair  to  be  diseased  and  usually  broken  off  close  to  the  scalp. 

Cause.  The  result  of  the  presence  and  growth  of  the  same  fungus 
giving  rise  to  tinea  circinata — trichophyton.  It  is  an  affection  of  child- 
hood, seldom  being  seen  after  puberty.  It  is  highly  contagious,  and 
may  be  communicated  from  a  case  of  ringworm  of  the  body. 

Pathology.  The  parasite  originally  named  "  trichophyton  tonsu- 
rans'' invades  the  hair,  hair  follicles  and  epidermis  of  the  scalp, 
the  hair,  however,  suffering  the  most  severely,  becoming  in  a  short 
time  filled  with  the  growth  to  such  an  extent,  usually,  as  to  cause  its 
disintegration  and  destruction.  The  hair  follicle,  also,  becomes  dis- 
tended and  prominently  raised.  The  hair  shaft  is  fractured  just 
above  the  level  of  the  scalp,  and  usually  presents  a  jagged,  bristly, 
stubble-like  extremity.  The  epidermis  of  the  scalp  may  either  pre- 
sent the  changes  of  minute  vesicles  and  desquamation,  or,  in  severe 
cases,  oedema  and  inflammatory  symptoms,  with  fluid  exudation  {tinea 
kerion).  ■ 

Symptoms.  Ringworm  of  the  scalp  usually  begins  in  the  form 
of  small  circumscribed  patches,  which  soon  become  the  seat  of  small 
vesicles  or  pustules,  which  terminate  in  desquamation,  or  of  furfur- 
aceous  scales.  The  patches  spread  rapidly,  soon  reaching  the  size  of 
a  silver  quarter  to  that  of  a  silver  dollar.  They  are  circular  in  form, 
circumscribed,  of  a  reddish,  grayish  or  greenish-yellow  color,  covered 
with  fine  or  coarse  scales,  with  the  hairs  broken  off  close  to  the  scalp. 
The  epidermis  of  the  scalp  is  more  or  less  raised  and  the  follicles  are 


DISEASES    OF   THE   SKIN.  437 

prominent,  giving  the  characteristic  appearance  of  the  disease — the 
goose-skin  or  plucked-fowl  appearance.  As  a  result  of  the  loss  of 
hair,  baldness,  more  or  less  complete,  but  temporary,  exists. 

Itching,  slight  or  severe,  is  a  constant  symptom. 

Ringworm  of  the  face  or  body  {tinea  circiftata)  may  complicate 
tinea  tonsurans. 

Chronic  ringworm  of  the  scalp  is  the  same  condition  in  a  more 
chronic  form,  having  existed  for  six  months  to  a  year  or  two. 

Tinea  kerion  is  a  severe  variety  of  tinea  tonsurans,  "characterized 
by  oedema,  inflammation,  and  the  exudation  of  a  viscid,  glutinous, 
yellowish  secretion  from  the  opening  of  the  hair  follicles.  When 
fully  developed  the  patches  are  yellowish,  reddish  or  purplish  in  color, 
and  are  more  or  less  raised,  cedematous  and  boggy.  They  are  uneven 
and  honeycomb-like  (whence  the  name  ken'on),  and  studded  with 
yellowish,  suppurative  points,  or,  later,  v/ith  small  cavities  or  foramina, 
the  openings  of  the  distended  hair  follicles  deprived  of  their  hairs, 
which  discharge  a  mucoid,  gummy,  honey-like  fluid." 

The  patches  are  tender,  painful  and  at  times  the  seat  of  itching. 
The  course  of  the  affection  is  chronic. 

Diagnosis.  The  diagnosis  is  usually  unattended  with  difficulty, 
if  the  characteristic  circumscribed  vesicular  or  scaly  patches  with 
stubby  hair  be  present. 

Squamous  eczema  somewhat  resembles  tinea  tonsurans,  but  the 
hairs  are  normal  in  eczema  and  firmly  imbedded  in  the  follicles, 
while  they  are  almost  always  stumpy  in  ringworm,  and  in  those  cases 
in  which  they  are  not  broken  off,  if  pulled,  they  easily  fall  out.  Ring- 
worm is  contagious,  eczema  is  not. 

Alopecia  areata  presents  a  white,  shiny,  ivory -like,  bald  patch, 
devoid  of  scales,  eruption,  or  hair.  Ringworm  has  the  vesicular  or 
scaly  patch,  with  broken-off  hairs. 

In  any  case  of  doubt  the  microscope  will  readily  determine  the 
diagnosis,  if  "  one  or  two  of  the  short  stumpy  hairs  should  be  placed 
upon  a  slide  with  a  drop  of  liquor  potasses  and  permitted  to  stand  a 
few  minutes,  when,  under  a  power  of  two  hundred  and  fifty  diameters 
the  fungus,  as  well  as  the  lesions  of  the  hair,  will  be  visible. 

Prognosis.  Favorable,,  although  obstinate  in  chronic  cases.  Re- 
lapses are  of  frequent  occurrence. 

Treatment.  ■  Local  measures  are  satisfactory  in  the  majority  of 
instances  of  tinea  tonsurans. 


438  PRACTICE   OF   MEDICINE. 

Mild  cases  should  be  treated  by  cuttting  the  hair  as  close  as  possible 
and  thoroughly  scrubbing  the  patches  with  j'tz/^  viridis  and  water,  and 
the  application  twice  daily  of  a  six  per  cent,  solution  of  oleatum  hy- 
drargyri,  or  either  of  the  following  : — 

R.     Sodii  borat., 5J 

Aceti  destil., f^xy  M. 

SiG. — Apply  thoroughly  several  times  daily. 

Or— 

R.     Acidi  boracici, gr.  xv 

Sulphur,  flor., gr.  xv 

Vaselini, f5iss.  M. 

SiG. — Apply  morning  and  night. 

Or,  use  may  be  made  of  Morris'  thymol  solution,  to  wit : — 

R.     Thymol, ^ss 

Chlorofurmi, 3  ij 

01.  olivse, ^vj.  M. 

A  preparation  very  popular  in  London,  known  as  Coster's  paste,  is 
used  by  painting  the  patches  with  a  brush  and  allowing  it  to  remain 
on  until  the  crust  is  cast  off,  in  the  course  of  five  or  six  days,  when 
it  maybe  reapplied.    A  few  applications  often  suffice.  Its  formula  is — 

R.     lodi, 3ij 

Olei  picis f3J.  M. 

The  iodine  and  oil  of  tar  should  be  gradually  and  slowly  mixed. 

An  excellent  application  in  rebellious  cases  is — 

R.     Potassse  (caustic), gr.  ix 

Acid  carbolici, gr.  xxiv 

Lanoline,     .    .^ 5ss 

01.  theobromse, •••....    5ss.  M. 

SiG. — A  small  amount  rubbed  into  head  night  and  morning.     If  the 
scalp  is  not  shaved  the  application  is  retained  better. 

Cases  which  resist  these  means  are  to  be  treated  by  removing  the 
loose  hairs  about  the  edges  of  the  patches,  and  the  broken-off  hairs 
over  the  surface,  by  means  of  small,  broad-bladed,  short  forceps,  a 
few  hairs  only  being  seized  at  a  time  ;  a  portion  of  the  diseased  hairs 
to  be  removed  each  day  until  the  surface  has  been  cleared.  After 
each  depilation,  one  of  the  above  formulae  is  to  be  applied. 


DISEASES   OF   THE   SKIN.  439 

TINEA  SYCOSIS. 

Synonyms.  Tinea  trichophytina  barbae;  sycosis  parasitica ;  bar- 
bers* itch  ;  ringworm  of  the  beard. 

Definition.  A  contagious,  parasitic  affection  of  the  hair,  hair 
folhcles  and  subcutaneous  tissues  of  the  hairy  portion  of  the  face  and 
neck  in  the  adult  male,  due  to  the  trichophyton  fungus ;  character- 
ized by  the  development  of  tubercles  and  pustules. 

Cause.  Tinea  sycosis  is  the  result  of  the  presence  and  growth  of 
the  same  vegetable  parasite  that  causes  tinea  circinata  and  tinea  ton- 
surans— trichophyton — which  invades  the  hair  follicle  and  hair.  It 
is  highly  contagious,  and  is  said  to  be  acquired,  in  most  cases,  at  the 
hands  of  the  barber  (?).  It  is  not  a  very  common  affection.  Like  the 
other  vegetable  growths,  it  seems  to  require  some  peculiar,  unknown 
condition  of  the  skin  for  its  development.  It  may  develop  from  a 
case  of  tinea  circinata  or  develop  simultaneously  with  it. 

Pathology.  The  parasite  finds  its  way  into  the  hair  follicles  and 
attacks  the  root  and  shaft  of  the  hair,  causing  inflammation,  followed 
by  more  or  less  follicular  suppuration  and  general  infiltration  of  the 
surrounding  tissues.  The  irritation  caused  by  the  presence  of  the 
fungus  results  in  inflammation  of  the  subcutaneous  connective  tissue 
and  the  well-known  tubercular  formations  peculiar  to  the  affection. 
They  are  firm,  comparatively  painless,  and  manifest  but  little  dispo- 
sition to  undergo  change,  remaining  during  the  presence  of  the  fungus 
and  finally  gradually  disappearing  without  leaving  a  scar.  Under 
the  microscope  the  parasite  is  plainly  discernible. 

Symptoms.  Barbers'  itch  begins  as  an  attack  of  tinea  circinata 
— as  one  or  more  reddish,  scaly  patches.  Soon  the  redness  and  des- 
quamation become  more  decided,  attended  with  swelling  and  indura- 
tion. The  hairs  will  also  be  dry,  brittle,  incline  to  break,  and  many 
of  them  are  already  loose.  The  process  rapidly  increases,  the  skin  be- 
comes distinctly  nodular  and  lumpy,  and  points  of  pustulation  develop 
about  the  openings  of  the  hair  follicles.  The  subcutaneous  connective 
tissue  is  also  involved,  giving  rise  to  thick,  firm  masses  of  induration. 

The  surface  has  a  dark  red  or  purplish  color,  and  is  studded  with 
variously-sized  tubercles  and  pustules.  In  some  instances  the  num- 
ber of  tubercles  are  in  excess,  while  in  others  the  pustules  are  more 
numerous,  numbers  of  them  discharging,  and  are  succeeded  by  thick 
crusts,  which  are  often  so  abundant  as  to  simulate  pustular  eczema. 


440  PRACTICE   OF   MEDICINE. 

The  hairs  are  always  diseased,  and  break  off,  either  in  the  follicles 
or  just  above  the  level  of  the  surface.  Those  not  breaking  drop  out, 
leaving  the  region  partly  or  wholly  devoid  of  hair. 

The  most  frequent  location  attacked  is  the  chin,  neck  and  sub- 
maxillary region.  One  or,  what  is  more  common,  both  sides  of  the 
face  are  involved. 

Itching,  burning  pain  and  swelling  2ihN2iys  accompany  the  affection, 
varying  in  intensity  from  moderate  to  very  severe. 

The  course  of  the  affection  is  usually  chronic.  Relapses  are  fre- 
quent, unless  most  thoroughly  eradicated. 

Diagnosis.  Sycosis  non-parasitic  a  occasions  difficulty  of  diag- 
nosis at  times.  The  points  of  difference,  however,  are  usually  so 
marked  that  error  should  not  occur. 

Sycosis  non-parasitica  is  a  chronic,  inflammatory,  non-contagious 
affection  of  the  hair  follicles,  characterized  by  the  development  of  pap- 
ules and  pustules,  which  are  perforated  with  hairs,  the  hairs  themselves 
being  unaffected.  The  upper  lip,  cheeks  and  chin  are  the  parts  mostly 
involved.     If  of  long  duration,  some  inflammatory  thickening  results. 

In  tinea  sycosis  or  sycosis  parasitica,  the  skin  and  subcutaneous 
connective  tissue  are  extensively  involved,  as  manifested  by  the  in- 
duration and  formation  of  the  characteristic  tubercles.  The  upper 
lip  is  rarely  invaded,  the  hairs  are  diseased,  broken  off  or  loose,  and 
under  the  microscope  reveal  the  parasite. 

Pustular  eczema  resembles  tinea  sycosis,  with  extensive  pustulation 
and  crusting.  But  in  the  former  the  hairs  are  not  involved,  nor  are 
the  characteristic  tubercles  present. 

Treatment.  Local  measures  are  sufficient  for  the  cure  of  tinea 
sycosis.  In  the  majority  of  instances  the  following  procedure  will 
effect  a  cure  in  three  or  four  weeks.  If  crusts  are  present,  and  almost 
always  some  are,  they  are  to  be  thoroughly  saturated  with  inunctions 
of  almond  or  olive  oil,  and  removed  by  washing  with  soft  soap  and 
water.  The  part  is  then  cleanly  shaved,  the  first  operation  being 
more  painful  than  subsequent  ones.  After  shaving,  the  affected  sur- 
face is  bathed  for  ten  minutes  in  water  as  hot  as  can  be  borne.  All 
pustules  are  then  opened  with  a  fine  needle,  after  which  the  parts  are 
sponged  freely  for  several  minutes  with  a  solution  of  sodii  hyposul- 
phitis,  ,5j,  aqucE,  f,^j,  after  which  the  parts  are  again  thoroughly 
washed  with  hot  water,  carefully  dried  and  smeared  with  an  un- 
guentum  sulphur.,  containing  Sj-ij  to  the  ounce.     This  procedure  is 


DISEASES   OF   THE  SKIN.  441 

preferably  performed  at  night.  The  following  morning  the  ointment 
is  washed  off  with  soap  and  water,  the  face  bathed  with  the  sodium 
solution,  and  dusted  with  any  inert  powder.  This  plan  continued 
faithfully  every  night,  omitting  the  shaving  when  the  beard  has  not 
grown  much,  will  usually  be  followed  with  success. 

Cases  resisting  the  above  means  should,  in  addition  to  the  above, 
have  the  hairs  depilated,  the  shaving  performed  every  two  or  three 
days,  thus  allowing  time  for  the  hairs  to  grow  sufficiently  to  depilate, 
the  operation  seldom  being  so  painful  as  one  would  suppose.  Shav- 
ing and  depilation  upon  alternate  days  should  be  faithfully  practiced 
until  the  new  hairs  show  themselves  to  be  healthy. 

In  addition  to  the  parasiticides  mentioned,  any  of  those  recom- 
mended for  the  other  vegetable  parasitic  diseases  may  be  used. 

TINEA  VERSICOLOR. 

Syiaonynis.     Pityriasis  versicolor ;  liver-spots. 

Definition.  A  contagious,  parasitic  affection  of  the  skin,  due  to 
the  Tnicrosporon  furfur ;  characterized  by  the  occurrence  of  variously- 
sized,  irregularly-shaped,  dry,  slightly  furfuraceous,  yellowish  spots 
upon  the  chest  or  other  portions  of  the  body. 

Cause.  Pityriasis  versicolor  is  the  result  of  the  presence  upon  the 
surface  of  the  skin  of  a  vegetable  fungus  termed  niicrosporon  furfur. 
It  is  a  mildly  contagious  affection  seen  after  puberty.  It  is  said  to 
occur  most  frequently  in  those  suffering  from  wasting  diseases,  partic- 
ularly phthisis  pulmonalis.  It  is  not  connected  with  any  affection  of 
the  liver,  as  supposed  by  the  laity. 

Pathology.  The  fungus  permeates  the  horny  layer  of  the  epi- 
dermis, never  the  hair  or  nail,  and  gives  rise  to  the  irregular-shaped 
and  sized  maculee,  of  a  yellowish  or  brownish  color.  As  a  rule,  it 
gives  rise  to  neither  hypersemia  nor  inflammatory  symptoms. 

Symptoms.  Tinea  versicolor  occurs  in  the  form  of  irregular, 
roundish,  circumscribed  or  reticulated  maculae.  The  spots  vary  in 
size  from  that  of  a  small  silver  coin  to  that  of  the  hand.  By  coal- 
escing they  often  cover  a  greater  portion  of  the  chest,  their  most  usual 
site.  Upon  close  inspection  the  surface  of  the  macule  is  seen  to  be 
covered  with  furfuraceous  scales,  and  if  the  scales  be  not  visible, 
scraping  with  the  finger  nail  will  demonstrate  their  presence.  In 
color  the  spots  vary  from  a  delicate  buff  or  fawn  shade  to  a  yellowish, 
37 


442  PRACTICE  OF   MEDICINE. 

deep  brown,  and,  rarely,  even  blackish  hue.  At  times  mild  itching 
accompanies  the  eruption. 

Diagnosis.  The  characteristics  of  the  eruption  are  so  distinct 
that  errors  in  diagnosis  can  hardly  occur.  If  any  doubt  exist,  a  few 
of  the  scales  placed  upon  a  glass  slide,  with  a  drop  of  liquor  potass(B, 
and  covered  with  a  thin  glass  cover  and  placed  under  a  microscope 
with  a  power  of  from  two  hundred  and  fifty  to  five  hundred  diameters, 
will  readily  determine  the  presence  of  the  fungus. 

Prognosis.     Favorable. 

Treatment.  The  parts  should  be  cleansed  with  soap  and  water, 
and  either  of  the  following  lotions  applied  : — 

R .     Sodii  sulphitis, ^iij 

Glycerini, f^ij 

Aquae, ad f ^  iv.  M, 

SiG. — Apply  frequently. 
Or— 

R.     Hydrargyri  chlorid.  corrosiv., gr- iv 

Alcoholis, f^yj 

Ammonii  muriat., 2ss 

Aquae  rosae, ad f  3  vj-  M. 

SiG. — Apply  frequently. 

— Tilbury  Fox. 

SCABIES. 

S3naonyin.    The  itch. 

Definition.  A  contagious,  animal  parasitic  disease  of  the  skin, 
due  to  the  acarus  or  sarcoptes  scabiei ;  characterized  by  the  forma- 
tion of  cuniculi  (burrows),  papules,  vesicles  and  pustules ;  followed 
by  excoriations,  crusts  and  general  cutaneous  inflammation,  and 
accompanied  with  itching. 

Cause.  Contagion.  The  only  cause  is  the  presence  of  the  ani- 
mal parasite,  the  acarus  or  sarcoptes  scabiei.  The  affection  occurs  at 
all  ages  and  in  every  walk  in  life. 

Pathology.  Scabies  is  an  inflammation  of  the  skin  with  the 
development  of  papules,  vesicles,  pustules,  excoriations  and  subse- 
quent crusting,  the  result  of  the  ravages  of  the  animal  parasite, 
together  with  the  irritation  produced  by  the  scratching  of  the  patient. 

The  parasite — acarus  or  sarcoptes  scabiei — is  a  minute  creature, 
barely  visible  to  the  naked  eye  as  a  yellowish-white,  rounded  body. 
The  female  is  the  most  commonly  met  with,  the  males  being  said  to 


DISEASES    OF   THE   SKIN.  443 

take  no  part  in  causing  the  affection,  and  so  are  rarely  seen.  They 
are  said  to  die  in  about  a  week  after  copulation  with  the  female.  The 
female  finds  her  way  by  boring  through  the  horny  layer  into  the 
mucous  layer  of  the  epidermis,  and,  being  impregnated,  begins 
at  once  laying  her  eggs  and  at  the  same  time  making  her  burrow. 
A  variable  number  of  eggs  are  deposited,  usually  about  a  dozen,  after 
which  she  perishes  in  the  skin.  The  ova  hatch  out  in  eight  or  ten 
days. 

Symptoms.  Scabies  being  an  artificial  dermatitis  or  eczema, 
according  to  the  amount  of  irritation  produced  by  the  presence  of  the 
parasite  and  the  traumatism  the  result  of  the  severe  scratching  of  the 
patient. 

Immediately  upon  the  arrival  of  the  itch  mite  upon  the  skin  it  begins 
its  work  of  burrowing,  and  very  soon  a  burrov/  or  cuniculus  is  formed, 
in  which  the  eggs  are  deposited,  and  which  also  becomes  the  habitat 
of  the  female  during  the  remainder  of  her  life.  The  ova  are  hatched 
in  about  one  week  after  their  deposit,  and  they  at  once  begin  to  care 
for  themselves  and  to  burrow,  resulting  in  the  formation  of  as  many 
additional  cunictdi  as  there  are  active  female  mites.  It  is  the  presence 
of  these  burrowing  parasites  that  constitutes  the  irritation  resulting  in 
the  inflammation  of  the  skin,  characterized  by  the  formation  of  minute 
papules,  vesicles  and  pustules,  with  more  or  less  inflammatory  indura- 
tion. Add  to  these  the  excoriations,  scratch  marks,  fissures,  torn 
vesicles,  and  pustules  with  yellow  and  bloody  crusts,  caused  by  the 
scratching,  and  a  picture  of  the  fully-developed  disease  is  seen. 

The  burrow,  or  cuniculus,  as  it  is  termed,  is  formed  by  the  mite 
entering  and  making  its  way  beneath  the  horny  layer  of  the  epidermis, 
which  is  raised,  very  much  as  a  mole  undermines  the  ground.  It 
occurs  as  a  slight  linear  elevation  of  the  epidermis,  varying  from  a 
half  a  line  to  four  or  five  lines  in  length,  and  having  an  irregular  or 
tortuous  course.  Its  color  is  whitish  or  yellowish,  speckled  here  and 
there  with  dark  dots.  At  either  end  the  cuniculus  terminates  as 
darkish  points,  the  more  prominent  of  which  represent  the  parasite. 

"Wi^ papules  are  the  first  inflammatory  lesion,  are  numerous,  and  of 
small  size,  and  may  be  the  extent  of  the  disease. 

The  vesicles  are  the  next  stage,  varying  in  size  and  number,  having 
an  inflamed  base,  sometimes  presenting  cunicula  upon  their  summits. 

The  pustules  represent  the  completion  of  the  inflammatory  action, 
their  size  and  number  varying  with  the  severity  of  the  irritation. 


444  PRACTICE   OF  MEDICINE. 

The  intense  itching,  which  is  worse  at  night,  results  in  excoriations, 
torn  papules,  vesicles  and  pustules,  followed  by  crustings,  which 
after  a  time  disguise  the  characteristic  lesions.  The  regions  of  the 
body  attacked  are  the  hands,  especially  the  sides  of  the  fingers 
and  the  folds  where  they  join  the  hands.  After  a  time  the  wrists, 
penis  and  manmias,  and  around  about  and  upon  the  nipples,  are 
invaded. 

Persons  predisposed  to  eczema  have  this  affection  developed,  in 
addition  to  the  simple  dermatitis,  by  the  ravages  of  the  itch  mite. 

Diagnosis.  A  case  of  scabies  seen  before  irritated  by  scratching 
presents  no  difficulty  in  diagnosis.  The  presence  of  the  burrows 
always  suffices  for  the  diagnosis,  but  these  are  not  always  discover- 
able. The  location  of  the  eruption  always  points  strongly  to  scabies. 
A  history  of  contagion  is  of  value.  All  doubt  can  be  set  at  rest  by  the 
aid  of  the  microscope. 

Prognosis.  Always  favorable,  relapses  only  occurring  when  the 
treatment  has  been  imperfectly  carried  out  or  where  the  individual 
has  re-contracted  the  disease. 

Treatment.  Local  measures  are  alone  required  in  the  treatment 
of  scabies.  The  strength  of  the  parasiticides  must  be  controlled  by 
the  severity  of  the  inflammatory  symptoms  present.  If  eczema  com- 
plicate scabies,  it  is  to  be  treated  as  an  ordinary  attack  after  the  death 
of  the  itch  mites. 

Scabies  always  succumbs  to  the  following  plan.  The  patient  is  to 
be  thoroughly  washed  with  soft  soap  and  water,  followed  by  a  warm 
bath,  after  which  one  of  the  following  ointments  is  to  be  thoroughly 
rubbed  into  every  portion  of  the  body,  special  attention  being  devoted 
to  the  hands,  fingers  and  other  parts  usually  the  seat  of  the  disease. 

R  .     Styracis  liquidis, ^^  ij 

Ung.  sulphuris, z  ij-iv 

Ung.  petrolei, ad 5J.  M. 

SiG. — Apply  after  washing. 

— BULKLEY. 


Or- 


1^.     Sulphuris  sublimat., .^j 

Balsam.  Peruviani, Zss 

Adipis, 5J.  M. 

SXG. — For  children. 

— DUHRING. 


DISEASES   OF  THE  SKIN.  445 

PEDICULOSIS. 

Synonyms.     Phthiriasis  ;  morbus  pedicularis  ;  lousiness. 

Definition.  A  contagious,  animal  parasitic  disease  of  the  head, 
body  or  pubes,  due  to  the  presence  of  pediculi  and  characterized  by 
the  wounds  inflicted  by  the  parasite,  together  with  excoriations  and 
scratch  marks. 

Varieties.  Pediculosis  capitis ;  pediculosis  corporis ;  pediculosis 
pubis. 

Cause.  The  cause  is  the  presence  of  the  parasite,  the  result  of 
contagion,  direct  or  indirect.  The  view  of  "  a  spontaneous  genera- 
tion "  of  pediculi  is  not  accepted  by  the  great  majority  of  observers. 

Pathology.  The  lesion  produced  by  the  presence  of  the  pediculi 
is  a  minute  hemorrhage,  caused  by  the  parasite  inserting  its  sucking 
apparatus,  or,  as  it  is  termed,  its  haustellum,  into  a  follicle,  and  obtain- 
ing blood  by  a  process  of  sucking,  and  not  by  biting,  as  is  generally 
supposed.  The  presence  of  the  parasite  in  any  great  numbers  brings 
about  a  peculiar  irritable  state  of  the  skin,  which  gives  rise  to  an  irre- 
sistible desire  to  scratch,  as  a  consequence  of  which  the  surface  is 
markedly  excoriated  and  lacerated. 

Symptoms.  The  symptoms  which  arise  from  the  presence  of  the 
parasite  in  different  localities  are  somewhat  different,  and  call  for 
separate  consideration. 

Pediculosis  capitis.  This  variety  is  caused  by  the  presence  of  the 
pediculosis  capitis  or  head  louse.  The  ova,  or  nits,  are  readily  recog- 
nized at  a  distance.  Their  favorite  seat  is  the  occipital  region,  either 
upon  the  surface  of  the  scalp  or  upon  the  hair.  Their  presence  gives 
rise  to  considerable  irritation,  itching  and  consequent  scratching, 
resulting  in  the  wounding  of  the  scalp,  with  oozing  of  a  serous  or 
purulent  fluid  mixed  with  blood,  which  soon  mats  the  hair  and  forms 
into  crusts.  In  those  predisposed  to  eczema,  the  presence  of  the  para- 
site will  give  rise  to  that  condition. 

The  general  health  is  usually  unaffected  by  the  presence  of  the 
pediculi. 

Pediculosis  corporis.  This  variety  of  pediculosis  is  caused  by  the 
presence  of  the  pediculus  corporis  or  body  louse,  or  more  properly 
termed  the  pediculus  vestimenti  or  clothes  louse.  Its  color,  when 
devoid  of  blood,  is  dirty -white  or  grayish,  with  a  dark  line  around  the 
margin  of  its   abdomen.     Its  habitat  is  the  clothing  covering  the 


446  PRACTICE   OF   MEDICINE. 

general  surface,  remaining  upon  the  skin  only  long  enough  to  obtain 
sustenance.  The  ova  are  usually  deposited  in  the  seams  of  the  cloth- 
ing, the  lice  being  hatched  within  the  week.  Occasionally  a  few  of 
the  pediculi  may  be  observed  crawling  about  the  surface,  or  in  the 
act  of  drawing  blood.  As  they  move  over  the  surface  they  give  rise 
to  an  intensely  disagreeable  itching  sensation,  to  relieve  which  the 
patient  scratches,  which  in  turn  gives  rise  to  the  characteristic  lesions 
of  the  affection. 

The  lesions  are  numerous.  The  scratch  marks  are  scattered  here 
and  there,  either  long  and  streaked,  in  other  places  short  and  jagged  ; 
the  excoriations  and  blood  crusts  varying  in  size  from  a  pin  head  to  a 
split  pea  or  even  larger,  with  irregularly-shaped  pustules.  In  addition 
to  the  lesions  resulting  from  the  scratching,  are  seen  the  primary 
lesions,  consisting  of  minute  reddish  puncta  with  slight  areolae,  the 
points  at  which  the  parasite  has  drawn  blood.  In  cases  of  long  stand- 
ing, a  brownish  pigmentation  of  the  whole  skin  may  result  from  the 
long-continued  irritation  and  scratching.  The  favorite  site  of  the 
lesions  are  the  back,  especially  about  the  scapular  region,  the  chest, 
abdomen,  hips  and  thighs. 

Pediculosis  is  seen  most  commonly  among  the  poorer  classes,  and 
especially  the  middle  aged  and  elderly. 

Pediculosis  pubis.  This  variety  of  pediculosis  is  caused  by  the  pre- 
sence of  the  pediculis  pubis  or  crab  louse.  Although  having  its  seat 
of  predilection  about  the  pubes,  it  may  also  infest  the  axillae,  sternal 
region  in  the  male,  beard,  eyebrows  and  even  eyelashes. 

They  may  be  found  crawHng  about  the  hairs,  but  more  commonly 
hugging  the  surface  closely.  They  infest  adults  chiefly,  and  occasion 
symptoms  similar  to  those  described  in  connection  with  other  species. 
They  are  usually  contracted  through  sexual  intercourse,  although 
occasionally  they  are  present  in  cases  in  which  they  have  not  been 
communicated  in  this  way,  and  where  no  explanation  as  to  the  mode 
of  contagion  can  be  suggested.  The  itchijig  varies  from  slight  to 
severe. 

Diagnosis.  When  violent  itching  exists  in  any  case,  without 
marked  eruption,  the  possibility  of  the  presence  of  pediculi  should 
always  be  entertained,  and  if  carefully  sought  after  are  found. 

Prognosis.    Favorable,  if  the  treatment  be  thoroughly  carried  out. 

Treatment.  Local  measures  alone  are  all  that  is  necessary  for 
the  removal  of  the  various  forms  of  pediculosis. 


DISEASES  OF  THE  SKIN.  447 

Pediculosis  capitis.  The  most  effective  application  of  this  variety 
is  to  thoroughly  soak  the  head  two  or  three  times  a  day  with  ordinary 
petroleum  or  kerosene  oil,  and  keep  it  wrapped  in  a  cloth  for  twenty- 
four  hours.  At  the  end  of  this  time  the  head  should  be  thoroughly 
washed  with  soft  soap  and  hot  water,  dried  and  saturated  with  the 
official  unguentum  hydrargyri  arnmoniati.  If  required,  this  entire 
procedure  may  be  repeated,  but  usually  any  pediculi  escaping  the 
petroleum  are  destroyed  by  the  unguentum. 

Pediculosis  corporis.  In  this  variety,  the  habitat  of  the  parasite 
being  the  clothing,  they  must  be  boiled  or  baked  at  a  temperature 
sufficiently  high  to  destroy  life.  After  this  the  clothing  should  be 
changed  every  day  or  two,  carefully  inspected,  and  if  pediculi  are 
seen  they  must  again  be  baked  or  boiled.  It  is  folly  to  expect  satis- 
factory results  unless  these  directions  be  faithfully  adhered  to.  For 
the  irritation,  itching  and  excoriations,  mild  alkaline  baths  or  lotions 
of  acidum  carbolicum  are  sufficient. 

Pediculosis  pubis.  The  parts  should  be  washed  twice  daily  with 
soft  soap  and  water,  after  which  the  thorough  application  of  tinctura 
cocculus  indicus,  full  strength  or  diluted,  or  a  lotion  of  hydrargyri 
chloridum  corrosivurn  or  unguentum  hydrargyri  ammoniati  will  be 
effectual. 


INDEX. 


Abdominal  dropsy,  105. 

typhus,  19. 
Abscess,  cerebral,  315. 

of  the  liver,  112. 

perityphlitic,  94. 
Acne,  413. 

artificialis,  414, 

disseminata,  413. 

indurata,  413. 

papulosa,  413. 

Piffard's  solution  for,  375. 

punctata,  374. 

pustulosa,  413. 

rosacea,  415. 

sebacea,  371. 

tuber cula,  413. 

vulgaris,  413. 
Aconite  in  erysipelas,  50- 
Aconitinse  in  neuralgia,  360. 
Acute  articular  rheumatism,  1 50. 

Bright's  disease,  125. 

gastric  catarrh,  58. 

gastritis,  60. 

general  diseases,  143. 

hepatitis,  112. 

meningitis,  306. 

yellow  atrophy,  114. 
Addison's  disease,  367,  423. 
Ague,  30. 

brow,  31. 

cake,  30. 

dumb,  30. 
Agraphia,  318. 

amnesic,  318. 
Albumin,  tests  for,  120,  121. 
Albuminuria,  126. 

chronic,  127. 
Alcoholism,  323. 

acute,  323. 

chronic,  323. 
Anaemia,  362. 

Blaud's  pill  for,  364. 


Anaemia,  cerebral,  298. 

essential,  365. 

of  fatty  heart,  365. 

progressive  pernicious,  365. 

splenica,  366. 
Ansematosis,  365, 
Anatomy,  morbid,  II. 
Angina  pectoris,  295. 
Anidrosis,  380. 
Antipyrine  in  migraine,  323. 
Anodynes,  compound  of,  70. 
Anthrax,  410. 
Aphasia,  317. 

amnesic,  317- 

ataxic,  318. 
Aphonia,  318. 
Aphthffi,  53. 

discrete,  53. 

confluens,  53. 
Apnoea,  13. 
Apoplexy,  302. 

serous,  311. 
Arachnitis,  306. 
Argyria,  423. 

Arteries,  Cohnheim's  terminal,  300. 
Arthritis  deformans,  157. 

mono-,  151. 

poly-,  151.  ^ 
Ascaris  lumbricoides,  lOO. 
Ascites,  105. 
Asthenia,  13. 
Asthma,  227. 

bronchial,  227. 

hay,  229. 

Kopp's  214. 

nervous,  227. 
Ataxia,  locomotor,  342. 
Atonic  dyspepsia,  70. 
Atrophy,  acute  yellow,  114. 

of  the  liver,  115. 
Aura  epileptica,  348. 
Auscultation,  181. 


449 


450 


INDEX. 


Auscultation,  Da  Costa's  rules  for,i82. 
Autumnal  fever,  19. 

Bacillus,  comma,  16S. 

malaria,  30. 

tuberculosis,  255. 

typhosus,  19. 
Bacteria  of  decomposition,  168. 
Barber's  itch,  439. 
Basedow's  disease,  354. 
Basham's  iron  mixture,  126. 
Bell's  palsy,  361. 
Belt,  hydropathic,  112. 
Biliary  calculi,  109. 
Bile,  test  for,  122. 

pigment,  test  for,  122. 
Bilious  fever,  32. 

malignant  fever,  37. 

remittent  fever,  32. 

typhoid  fever,  29. 
Biliousness,  no. 
Black-heads,  374. 
Bladder,  catarrh  of,  138. 
Blaud's  pill,  364. 
Bleeders'  disease,  368. 
Blepharospasm,  347. 
Blisters  in  rheumatism,  154. 

vk'Eter,  404. 
Blood  currents,  direct,  271. 

indirect,  271. 

test  for,  121. 

white  cell,  366. 
Bloody  flux,  90. 
Boil,  408. 
Borborygmus,  67. 
Bothriocephalus  latus,  98. 
Bowels,  inflammation  of,  79. 
Brain,  congestion  of,  297. 
Break-bone  fever,  51. 
Bright's  disease,  acute,  125. 

chronic,  127,  130. 
Bromidrosis,  377. 

pedum,  378. 
Bronchial  dilatation,  224. 

hemorrhage,  236. 
Bronchitis,  acute,  216. 

capillary,  219,  248. 

catarrhal,  216. 

chronic,  224, 

croupous,  222. 

diphtheritic,  222. 


Bronchitis,  fetid,  225. 

membranous,  222. 

peri-,  249. 

plastic,  222. 

secondary,  224. 
Broncho-pneumonia,  219,  248. 
Bronchorrhagia,  236. 
Bronchorrhoea,  225. 
Bronzed-skin  disease,  367. 

Caecum,  catarrh  of,  93. 
Calculi,  alternating,  137. 

biliary,  109. 

cutaneous,  375. 

hepatic,  109. 

oxalate  of  lime,  137. 

phosphatic,  137. 

renal,  136. 

uric  acid,  137. 
Callositas,  425. 
Callus,  425. 
Cancer,  gastric,  65. 

hepatic,  1 17. 
Carbuncle,  410. 
Carbunculus,  410. 
Carcinoma,  gastric,  65. 
Cardiac  dilatation,  282. 

fatty  degeneration,  285. 

hypertrophy,  280. 

murmurs,  270. 

paralysis,  147, 

see-saw  murmurs,  291. 

valvular  diseases,  286. 
Cardialgia,  69. 
Catalepsy,  352. 
Catarrh,  acute  bronchial,  216. 

acute  gastric,  58. 

acute  nasal,  193. 

autumnal,  229. 

chronic  bronchial,  224. 

chronic  gastric,  61. 

chronic  nasal,  196. 

contagious,  17. 

dry,  225. 

mucous,  225. 

of  the  bile  ducts,  107. 

of  the  bladder,  138. 

of  the  caecum,  93. 

of  the  mouth,  52. 

of  the  rectum,  95. 

sec.  of  Laennec,  225, 


INDEX. 


451 


Catarrh,  suffocative,  219. 
Catarrhal  enteritis,  79. 

jaundice,  107. 

nephritis,  124. 

stomatitis,  52. 

tonsillitis,  198. 
Cephalodynia,  155. 
Cerebral  abscess,  315. 

anaemia,  298. 

congestion,  297. 

embolism,  299. 

fever,  306. 

hemorrhage,  302. 

hypersemia,  297. 

softening,  303. 

thrombosis,  299. 

tumors,  316. 
Cerebro-spinal  fever,  26. 

neuroses,  346. 
Cervico-brachial  neuralgia,  358. 
Cervico-occipital  neuralgia,  358. 
Chicken-pox,  48. 
Child- crowing,  208. 
Chills  and  fever,  30. 
Chloasma,  422. 

uterinum,  423. 
Chlorides,  test  for,  120. 
Chlorosis,  363. 
Cholera,  168. 

Asiatic,  168. 

asphyxia,  170. 

bilious,  81. 

English,  82, 

epidemic,  168. 

infantum,  87, 

malignant,  168. 

morbus,  82. 

saline  fluids  in,  172. 

solution,  Bartholow's,  172. 

spasmodic,  168. 

sporadic,  82, 

typhoid,  169. 
Cholerine,  186. 
Chorea,  346. 

post-hemiplegic,  304,  347. 
Chromidrosis,  377. 
Chronic  dyspepsia,  61. 

gastric  catarrh,  61. 

gastritis,  61. 
Clark's  treatment  of  peritonitis,  104. 
Clavus,  426. 


Clinical  history,  12. 

Cohnheim's  terminal  arteries,  300. 

Cold  on  the  chest,  216. 

in  the  head,  193. 
Colic,  hepatic,  109. 

intestinal,  74. 

lead,  74. 

ovarian,  75. 

renal,  136. 

stomachic,  69. 

uterine,  75. 
Colitis,  90. 

ulcerative,  90. 
Coma,  13. 

ursemic,  135. 
Comedo,  374. 
Comedones,  374. 
Comma  bacillus,  168. 
Congestion,  cerebral,  297. 

of  the  kidneys,  1 24. 

of  the  lungs,  238. 
Congestive  fever,  33. 
Constipation,  75. 

glycerinum  for,  76. 
Consumption,  pulmonary,  251. 

galloping,  260. 
Contagious  fever,  25. 

catarrh,  17. 
Convulsions,  uraemic,  135. 
Corns,  426. 

soft,  427. 
Corrigan's  disease,  258. 

hammer,  327. 

sign,  66. 
Coryza,  acute,  193. 

chronic,  196. 
Coster's  paste,  438. 
Costiveness,  75. 
Cough,  winter,  224. 
Crackling,  244. 
Crepitatio  redux,  245. 
Crisis,  13. 
Croup,  catarrhal,  208. 

false,  208. 

membranous,  210. 

pseudo,  214. 

spasmodic,  208. 

true,  210. 
Croupous  enteritis,  81. 

laryngitis,  210. 

stomatitis,  53. 


452 


INDEX. 


Cry,  hydrocephalic,  311. 
Cyst,  renal,  133. 

sebaceous,  376. 
Cysticercus  cellulosus,  98. 

bovis,  98. 
Cystitis,  138. 

acute,  138. 

chronic,  138. 

Dandruff,  371. 
Dandy  fever,  51. 
Death,  13. 
Declat  syrup,  42. 
Degeneration,  caseous,  252. 

reaction  of,  338. 
Delirium  tremens,  325, 
Dengue,  51. 

Dewees'  mouth  caustic,  55* 
Diabetes  insipidus,  1 66. 

mellitus,  162, 
Diagnosis,  13. 

by  exclusion,  13. 

differential,  13. 

direct,  13. 

physical,  174. 
Diarrhoea,  77. 

acute,  77,  79. 

biUous,  77. 

choleriform,  87. 

chronic,  78. 

feculent,  77. 

inflammatory,  85. 

lienteric,  77. 

mixture,  Squibb's,  78. 
Diathesis,  12. 
Dilatation,  bronchial,  224. 

cardiac,  282. 

gastric,  67. 
Diphtheria,  144. 

bronchial,  222. 

laryngeal,  1 46,  2lo. 

nasal,  146. 
Diphtheritic,  paralysis,  147. 

stomatitis,  54. 
Dipsomania,  326. 
Discharges,  chopped  spinach,  86. 

rice  water,  80,  83,  169. 
Disease,  9. 

acute,  12. 

Addison's,  367,  423. 

Basedow's,  354. 


Disease,  bleeders',  368. 

Bright's,  135,  127, 130. 

causes  of,  1 1 . 

chronic,  13. 

Corrigan's,  258. 

defined,  9. 

Duchenne's,  340. 

fish-skin,  429. 

flesh-worm,  172. 

Fothergill's,  358. 

functional,  9. 

Graves',  354. 

Meniere's,  319. 

organic,  9. 

predisposition  to,  ii. 

subacute,  13. 

termination  of,   13, 
Diseases,  acute,  general,  143. 

of  the  biliary  passages,  107. 

of  the  blood,  362. 

of  the  bronchial  tubes,  216. 

of  the  circulatory  system,  268. 

of  the  intestinal  canal,  72. 

of  the  kidneys,  1 18. 

of  the  larynx,  203. 

of  the  liver,  no. 

of  the  lungs,  238. 

of  the  mouth,  52. 

of  the  nasal  passages,  193. 

of  the  nerves,  357. 

of  the  nervous  system,  297. 

of  the  peritoneum,  102. 

of  the  pharynx,  198. 

of  the  pleura,  261. 

of  the  respiratory  system,  174. 

of  the  skin,  371. 

of  the  spinal  cord,  331. 

of  the  stomach,  58. 
Disorders  of  secretion,  371. 
Dizziness,  319. 
Dropsy,  cutaneous,  40. 

of  the  abdomen,  105. 

pericardial,  277. 

peritoneal,  105. 

pleural,  265. 
Duchenne's  disease,  340. 
Duodenitis,  79. 
Dysentery,  acute,  90. 

epidemic,  90. 

sporadic,  90. 

washing  rectum  in,  92. 


INDEX. 


453 


Dyspepsia,  70. 
acid,  71. 
atonic,  70. 
chronic,  61. 
drunkard's,  61. 
flatulent,  71. 
hot  water  in,  62. 
intestinal,  72. 
irritative,  71. 
nervous,  71. 

Ecstasy,  352. 
Ecthyma,  407. 
Eczema,  382. 

acute,  385. 

ani,  394. 

aurium,  393. 

barbae,  392, 

capitis,  390. 

chronic,  385. 

erythematosum,  383. 

faciei,  392. 

fissum,  385. 

genitalium,  394. 

impetiginosum,  384. 

intertrigo,  383,  395. 

labiorum,  392. 

madidans,  384. 

mammarum,  395. 

marginatum,  434. 

palmarum,  396. 

palpebrarum,  392. 

papillomatosum,  385. 

papulosum,  384. 

plantarum,  396, 

pustulosum,  384. 

rimosum,  385, 

rubrum,  384. 

sclerosum,  385. 

squamosum,  385. 

unguium,  396. 

universale,  383. 

verrucosum,  385. 

vesiculosum,  383. 
Electrical  storm,  348. 
Elixir,  triple,  286. 
Embolism,  cerebral,  299. 
Emetic,  Dr.  Fordyce  Barker's,  213. 
Emphysema,  233. 
Empyema,  262. 
Encephalitis,  acute,  315. 


Encephalitis,  suppurative,  315. 
Endocarditis,  acute,  277. 
Enteralgia,  74. 
Enteric  fever,  19. 
Enteritis,  catarrhal,  79. 

croupous,  81. 

membranous,  81. 
Entero-colitis,  85. 

mesenteric  fever,  19. 
Enterorrhoea,  77. 
Ephemeral  fever,  16. 
Epidemic  catarrhal  fever,  17. 

cerebro-spinal  fever,  26. 

roseola,  44. 
Epilepsy,  348. 
Errhine,  Ferrier's,  195. 

Robinson's,  196. 
Erysipelas,  49. 

ambulans,  49. 

of  the  brain,  49. 

phlegmonous,  49. 
Erysipelatous  dermatitis,  49. 
Erythema  simplex,  380. 

intertrigo,  381. 
Erythematous  stomatitis,  52. 
Essential  anaemia,  365. 
Etiology,  II. 

Eucalyptol  in  cystitis,  140. 
Exophthalmic  goitre,  354. 

Facial  paralysis,  361. 
Famine  fever,  29. 
Favus,  431. 
Febricula,  16. 
Ferrier's  errhine,  195. 
Fever,  14. 

abdominal  typhus,  19. 

autumnal,  19. 

bilious,  32. 

bilious  remittent,  32. 

bilious  typhoid,  29. 

breakbone,  51. 

catarrhal,  17. 

cause  of,  14. 

cerebral,  306. 

cerebro-spinal,  26. 

congestive,  33. 

contagious,  25. 

continued,  16. 

dandy,  51. 

enteric,  19. 


454 


INDEX. 


Fever,  entero-mesenteric,  19. 

ephemeral,  16, 

epidemic  cerebro-spinal,  26. 

essential,  15. 

famine,  29, 

gastric,  19,58. 

hay.  229. 

intermittent,  30. 

irritative,  16. 

jail,  25. 

lung,  241. 

malarial,  30. 

malignant  intermittent,  23- 

malignant  remiitent,  23- 

marsh,  32. 

Mediterranean,  37. 

nervous,  19. 

neuralgic,  51. 

pernicious,  33. 

relapsing,  29. 

remittent,  32. 

rheumatic,  150. 

rose,  229. 

sailors',  37. 

scarlet,  39, 

secondary,  15. 

ship,  25. 

simple,  continued,  16. 

spotted,  26. 

swamp,  30. 

typhoid,  19. 

typho-malarial,  32. 

thermic,  329. 

typhus,  25. 

winter,  241. 

yellow,  37. 
Fevers,  14. 

continued,  16. 

eruptive,  39. 

essential,  15. 

general  treatment  of,  15. 

periodical,  30. 

primary  cause  of,  14. 

secondary,  15. 
Fish-skin  disease,  429. 
Flesh -worm  disease,  172. 
Floating  kidney,  141. 
Fluxes,  vicarious,  77. 
Follicular  stomatitis,  53. 
Fothergill's  disease,  358. 

fever  mixture,  17. 


Freckles,  421. 
Fremitus,  bronchial,  176. 

friction,  176. 

tussive,  176. 

vocal,  176. 
Furuncle,  408. 
Furunculus,  408. 
Furmiculosis,  408. 

Gall  stones,  109. 
Gastralgia,  69. 
Gastric  cancer,  65. 

carcinoma,  65. 

dilatation,  67. 

fever,  19. 

hemorrhage,  68. 

neuralgia,  69. 

ulcer,  63. 
Gastritis,  acute,  60, 

chronic,  61. 

subacute,  61. 

toxic,  60. 
Gastrodynia,  69. 
Gastrorrhagia,  68. 
Gastroscope,  uses  of,  66. 
German  measles,  44. 
Girdle,  a,  400. 
Glossitis,  56. 
Glottis,  oedema  of,  206. 

spasm  of,  214. 
Glycosuria,  162. 

simple,  164. 
Goudron  de  Guyot,  389. 
Gout,  150. 

half,  161. 

rheumatic,  157. 
Gravel,  136. 
Graves'  disease,  354. 
Green  sickness,  363. 
Gripes,  74. 

Gross',  Prof  S.  D.,  neuralgic  pill,  360. 
Grutum,  375. 
Gutta  rosea,  415. 

rosacea,  415. 

Hjematemesis,  68. 

Haematoma  of  the  dura  mater,  308. 

Ha-mophilia,  368. 

Haemoptysis,  236. 

Heat  stroke,  329. 

Heart,  anaemia  of  fatty,  365. 


INDEX. 


455 


Heart,  dilatation  of,  282. 

fatty  degeneration  of,  285. 
hypertrophy  of,  280. 

irritable,  294. 

neuralgia  of,  295. 

palpitation  of,  294. 

physical  examination  of,  268. 

valvular  diseases  of,  286. 
Heartburn,  70. 
Hemicrania,  321. 
Hemiplegia,  304. 
Hemorrhage,  bronchial,  236. 

cerebral,  302. 

gastric,  68. 

renal,  137. 
Hemorrhagic  diathesis,  368. 
Hemorrhcea  petechialis,  370. 
Hepatic  cancer,  117. 

colic,  109. 

calculi,  109. 
Hepatitis,  acute,  112. 

general  parenchymatous,  1 14. 

interstitial,  115. 

parenchymatous,  1 12. 

suppurative,  112. 
Herpes,  299. 

circinatus,  433. 

facialis,  399. 

gestationis,  4CX>, 

labialis,  399. 

praeputialis,  400. 

progenitalis,  400. 

tonsurans,  436. 

zoster,  400. 
Histology,  II. 
Hives,  396. 
Hooping  cough,  231, 
Hydrsemia,  362. 
Hydro-adenitis,  409. 
Hydrocephalus,  acquired,  3 II, 

acute,  310,  311. 

chronic,  313. 

congenital,  313. 
Hydropathic  belt,  112. 
Hydropericardium,  277. 
Hydropneumothorax,  266. 
Hydrosis,  377. 
Hydrothorax,  265. 
Hypersemia,  cerebral,  297. 

renal,  124. 

spinal,  331. 


Hypersemias  of  the  skin,  380. 
Hyperidrosis,  377. 

local,  377. 

unilateral,  378. 
Hypertrophies  of  the  skin,  421. 
Hypertrophy,  cardiac,  280. 
Hysteria,  350. 
Hystero-epilepsy,  352. 

Ichthyosis,  429. 
Icterus,  107. 

hemorrhagic  1 14. 
Ileo-colitis,  79. 
Impetigo,  406. 
Incubation,  period  of,  12. 
Indigestion,  70. 

acute,  58. 

intestinal,  72. 
Inflammation  of  the  skin,  382 
Influenza,  17. 
Insolation,  329. 
Inspection,  175. 
Intercostal  neuralgia,  400. 
Intermittent  fever,  30. 
Intestinal  colic,  74. 

dyspepsia,  72. 

obstruction,  96. 

parasites,  98. 

strictvire,  96. 

torpor,  75. 
Intestines,  diseases  of,  72. 

irrigation  of,  97. 
Introduction,  9. 
Invagination,  96. 
Ipecacuanha  in  dysentery,  92 
Iron  lemonade,  363. 
Irritative  fever,  16. 
Ischaemia,  362. 
Itch,  442. 

barbers',  439. 

Jail  fever,  25. 
Jaundice,  catarrhal,  107. 
malignant,  114. 

Kidneys,  amyloid,  131. 
congestion  of,  124. 
contracted,  120. 
diseases  of,  118. 
floating,  141. 
gouty,  130. 


456 


INDEX. 


Kidneys,  lardaceous,  131. 

movable,  141. 

sclerosis  of,  130. 

small  red,  130. 

wandering,  141. 

waxy,  131. 

white,  large,  127. 
Klebs'  micrococci,  39. 
Kummertield's  lotion,  417. 

Laryngismus  stridulus,  214. 
Laryngitis,  acute  catarrhal,  203. 

croupous,  210. 

oedematous,  206. 

spasmodic,  208. 
Law  of  parallelism,  151. 
Lentigo,  421. 
Lepra,  418. 
Leprosy,  English,  418. 
Leptomeningitis,  spinalis,  332. 
Leucaemia,  366. 
Leucocythemia,  366. 
Lichen  simplex,  384. 

tropicus,  402. 
Liquor  picis  alkalinus,  389, 
Lithaemia,  161, 
Lithiasis,  1 61. 
Liver,  abscess  of,  112. 

albuminoid,  1 16. 

amyloid,   116. 

atrophy  of,   115. 

carcinoma  of,  117. 

cirrhosis  of,  115. 

congestion,  1 10. 

diseases  of,  no. 

gin  drinkers',  1 15. 

hob-nailed,  115. 

hypertrophic  sclerosis  of,  115. 

lardaceous,  1 1 6. 

nutmeg,  ill. 

sclerosis  of,  115. 

scrofulous,  116. 

spots,  422,  441. 

torpid,  no. 

w4xy,  116. 

yellow  atrophy  of,  1 14. 
Locomotor  ataxia,  342. 
Lotio  nigra,  387. 
Lousiness,  445. 
Lumbago,  155. 
Lumbo-abdominal  neuralgia,  359. 


Lumbodynia,  155. 
Lungs,  cirrhosis  of,  258. 

congestion  of,  238. 

consumption  of,  251. 

gangrene  of,  242. 

hyperemia  of,  238. 

oedema  of,  240. 
Lysis,  13. 

Malignant  intermittent  fever,  33. 

remittent  fever,  33. 
Mai  le  grand,  348. 
Mai  le  petit,  348. 
Malarial  fever,  30. 
Mania-a-potu,  325 
Marsh  fever,  32. 
Measles,  32. 

black,  43. 

false,  44, 

French,  44. 

German,  44. 
Mediterranean  fever,  37. 
Megrim,  321. 
Melangemia,  30. 
Melasma,  supra-renalis,  367. 
Melituria,  162. 
Meniere's  disease,  3I9. 
Membranous  enteritis,  81. 
Meningitis,  acute,  306. 

basilar,  310. 

cerebro -spinal,  epidemic,  26, 

spinal,  332. 

tubercular,  310. 
Mensuration,  176. 
Metastasis,  13. 
Migraine,  321. 
Miliaria,  402. 

alba,  400. 

papulosa,  403. 

rubra,  402. 

vesiculosa,  403. 
Milium,  375. 
Mixture,  Bartholow's  cholera,  84. 

Basham's  iron,  128. 

Brovvn-Sequard's,    for    epilepsy, 

350. 
Da  Costa's  muscular  cramps,  84. 
Davis's  asthma,  229, 
Fothergill's  fever,  17. 
Hartshorne's  cholera,  84. 
Hope's  camphor,  87. 


INDEX. 


457 


Mixture,   Keating's    pertussis    spray, 

233- 

Pepper's  asthma,  229. 

Smith's  tonic,  363. 

Squibb' s  diarrhoea,  78. 
Morbid  anatomy,  ii. 
Morbilli,  42. 
Morphina  in  acute  uraemia,  136. 

in  cardiac  dilatation,  284. 
Morris's  thymol  solution,  438. 
Moth,  422. 
Moussette's  pill,  360, 
Mouth,  catarrh  of,  52. 

diseases  of,  52. 

psoriasis  of,  57. 

white,  55. 
Movable  kidney,  141. 
Mucus,  test  for,  120. 
Muguet,  55. 
Mumps,  143. 
Murmurs,  aortic,  272. 

endocardial,  270. 

exocardial,  270. 

mitral,  271. 

pericardial,  270. 

pulmonic,  272. 

see-saw,  291. 

tricuspid,  272, 
Muscles,  insanity  of,  346. 
Myelitis,  acute,  335. 
Myocarditis,  279. 

Nasal,  acute  catarrh,  193. 

chronic  catarrh,  196. 
Nephritis,  acute  desquamative,  125. 

catarrhal,  124. 

chronic  parenchymatous,  127. 

interstitial,  130. 

parenchymatous,  125. 

peri-,  134. 

pyelo-,  133. 

suppurative,  133. 

tubal,  125,  127, 
Nephro-lithiasis,  136. 
Nephrosis-pyelo,  136. 
Nervous  dyspepsia,  71. 

exhaustion,  353. 

fever,  19. 

prostration,  353, 
Nettle-rash,  396. 
Neuralgia,  358. 
38 


Neuralgia,  cervico-brachial,  358. 

cervico-occipital,  358. 

dorso-intercostal,  359, 

intercostal,  400. 

lumbo-abdominal,  359. 

of  the  fifth  nerve,  358. 

of  the  heart,  295. 

sciatic,  359. 
Neuralgic  fever,  51. 
Neurasthenia,  353. 
Neuritis,  357. 

Neuroses,  cerebro  spinal,  346. 
Nickel  in  epilepsy,  350. 
Nomenclature,  9,  10. 
Nystagm.us,  347. 

Obstruction,  aortic,  290. 

intestinal,  96. 

mitral,  290. 

pulmonic,  291. 

pyloric,  67. 

tricuspid,  291, 
Occlusion  of  cerebral  vessels,  299, 
Oidium  albicans,  55. 
Oinomania,  326. 

Ointment,  diachylon,  Hebra's,  390. 
Oligaemia,  362. 
Oxyuris  vermicularis,  100. 
Ozsena,  197. 

Pachymeningitis,  308. 

spinalis,  334. 
Pains,  the  girdle,  335. 
Palpation,  176. 
Palsy,  Bell's,  361. 

wasting,  344. 
Paragraphia,  318. 
Paralysis,  304, 

bilateral,  304. 

bulbar,  339. 

cardiac,  147. 

chronic  progressive  bulbar,  339. 

crossed,  304. 

diphtheritic,  147. 

essential,  of  infants,  337. 

facial,  361. 

glosso-labio-laryngeal,  339. 

infantile  spinal,  337. 

of  the  tongue,  318, 

pharyngeal,  147. 

unilateral,  304. 


45S 


INDEX. 


Paraphasia,  31S. 
Parasites,  intestinal,  98. 
Parasitic  diseases  of  the  skin,  431. 
Parotiditis,  143. 

metastatic,  143. 
Paste,  Costers,  438. 
Pathogenesis,  1 1. 
Pathognomonic,  13. 
Pathology,  9. 
Pediculosis,  445. 

capitis.  445. 

corpDris,  445. 

pubis,  446. 
Pemphigus,  404. 

foliaceus,  405. 

malignus,  405. 

pruriginosus,  405. 

vulgaris,  404. 
Percussion,  177 

auscultatory,  181. 

immediate,  177. 

mediate,  177. 

objects  of,  178. 

respiratory,  l8l. 
Pericarditis,  acute,  273. 

chronic,  275. 

dry,  273. 
Pericardium,  adherent,  276. 

effusion  of,  273. 

hydro-,  277. 
Peri  nephritis,  134. 
Periodical  fevers,  30. 
Peri-proctitis,  95. 
Peritoneal  dropsy,  105. 
Peritonitis,  102. 

saline  purgatives  in,  104. 
Peri-typhlitis,  95. 
Pernicious  fever,  33. 
Pertussis,  231. 
Pharyngeal  paralysis,  147. 
Pharyngitis,  acute  catarrhal,  198. 

erysipelatous,  200. 

exanthematous,  199. 

fibrinous,  200. 

gangrenous,  200. 

phlegmonous,  200,  201. 
Phosphates,  tests  for,  1 20. 
Phosphoridrosis,  377. 
Phthiriasis,  445. 
Phthisis,  251. 

acute,  260. 


Phthisis,  caseous,  251. 

catarrhal,  251. 

chronic,  258. 

fibroid,  258, 

Florida,  253. 

incipient,  255. 

pneumonic,  251. 

pulmonalis,  251. 

subacute,  251. 

tubercular,  255. 
Physical  diagnosis,  174. 

signs,  13-    .    . 

signs,  association  of,  192. 
PifFard's  acne  solution,  375. 
Pill,  Bartholow's  gout,  1 60. 

Blaud's,  364. 

DaCosta's,  for  hemorrhage,  238. 

Gross's  neuralgic,  360. 

Loomis's  gout,  1 61. 

Moussette's,  360. 

Niemeyer's,  258. 
Pilocarpus   for   spreading  erysipelas, 

so- 
Pitting,  to  prevent,  47. 
Pityriasis,  37 1. 

versicolor,  441. 
Pleurisy,  261. 
Pleuritis,  261. 

chronic,  262. 

dry,  262. 
Pleurodynia,  155. 
Pleuro-pneumonia,  241. 
Pneumonia,  bilious,  244. 

caseous,  251. 

catarrhal,  248. 

chronic  catarrhal,  251. 

chronic  interstitial,  258. 

croupous,  241. 

lobar,  241. 

lobular,  248. 

typhoid,  243. 
Pneumonitis,  241. 
Pneumothorax,  266. 
Podagra,  159. 

Poliomyelitis  anterior  acuta,  337, 
Polyuria,  166. 

Posterior  spinal  sclerosis,  342. 
Poultice,  pilocarpus,  156. 

spice,  87. 
Predisposition,  11. 

acquired,  12. 


INDEX. 


459 


Predisposition,  inherited,  12. 

Prickly  heat,  402. 

Proctitis,  95. 

Proctitis,  peri-,  95, 

Prodromes,  12. 

Prognosis,  13. 

Progressive  muscular  atrophy,  344. 

pernicious  anaemia,  365. 
Psoriasis,  418. 

circinata,  419. 

diffusa,  419. 

guttata,  419. 

gyrata,  419. 

mummularis,  419. 

of  the  mouth,  57. 

of  the  tongue,  57. 

palmaris,  419. 

plantaris,  419. 

punctata,  419. 

unguium,  419. 
Pulse,  Corrigan,  288. 

receding,  288. 
Purging,  77. 
Purpura,  370. 

hemorrhagica,  370. 

simplex,  370. 

urticans,  370. 
Pus,  test  for,  121. 
Pyelitis,  133. 
Pyelo-nephritis,  133. 

nephrosis,  133. 
Pyloric  obstruction,  67. 

stenosis,  67. 
Pyrosis,  70. 

Quinina  in  trichinosis,  1 74, 
Quinsy,  201. 

guaiacum  in,  202. 

malignant,  144. 

Rales,  187. 

bronchial,  189. 

cavernous,  189. 

dry,  188. 

laryngeal,  188. 

moist,  188. 

pleural,  190. 

tracheal,  i88. 

vesicular,  189. 
Reactions  of  degenerations,  338. 
Rectitis,  95. 


Rectum,  catarrh  of,  95. 

washing  out  the,  92. 
Regurgitation,  aortic,  288. 

mitral,  287. 

pulmonic,  289. 

tricuspid,  289. 
Relapsing  fever,  29. 
Remittent  fever,  32. 
Renal  cyst,  133. 
Respiration,  Cheyne-Stokes',  285. 

oscillating,  286. 
Rheumatic  fever,  150. 

gout,  157. 
Rheumatism,  acute  articular,  150. 

gonorrhoeal,  152. 

hyperpyrexia  of,  151. 

inflammatory,  150. 

muscular,  154. 
Rheumatoid  arthritis,  157 
Rhinitis,  acute,  193. 
i  chronic,  196. 

'    Rhinophyma,  416 
Ringworm,  honeycombed,  431. 

of  the  body,  433. 

of  the  scalp,  436. 

of  the  beard,  439. 
Robinson's  errhine,  196. 
Rosacea  gutta,  415. 
Rosea  gutta,  415. 
Rose,  the,  49. 
Rotheln,  44. 
Round  worms,  100. 
Rubeola,  42. 


Sailors'  fever,  37. 

Saline  fluids  in  cholera,  1 72. 

Salt  rheum,  382. 

Sand,  renal,  138. 

Sapo  viridis,  389. 

Scabies,  442. 

Scall,  382. 

Scarlatina,  39. 

mixture.  Smith's,  363. 
Scarlet  fever,  39. 
Sciatica,  359. 
Sclerosis,  lateral,  341. 

cerebro- spinal,  34I. 

disseminated,  341. 

hepatic  hypertrophic,  115. 

of  the  liver,  115. 


460 


INDEX. 


Sclerosis,  posterior,  342. 

spinal,  340. 
Scorbutus,  368. 
Scurvy,  36S. 
Sebaceous  cyst,  376. 
Seborrhoea,  371. 

capitis,  372. 

faciei,  372, 

oleosa,  372. 

sicca,  372. 
Secondary  processes,  13. 
Shingles,  400. 
Ship  fever,  25. 
Sick-headache,  321. 

antipyrine  in,  323. 
Sickness,  green,  363. 
Sign,  Corrigan's,  66 
Signs,  12. 

physical,  association  of,  192. 
Silver  nitrate  in  phlegmonous  erysipe- 
las, 50. 
Skin,  hypersemias  of,  380. 

inflammation  of,  382. 
Smallpox,  44. 

Smith's,  Dr.  A.  H.,  tonic,  363. 
Solution,  Dobell's,  197. 

Tanret's,  of  pelletierine,  100. 
Sore  throat,  acute,  198. 

putrid,  144. 
Sounds,  in  disease,  chest,  184. 

in  health,  chest,  183. 

normal  cardiac,  269. 
Spansemia,  362. 
Spasm,  histrionic,  347. 
Spinal  sclerosis,  340. 

hyperemia,  331. 

irritation,  353. 

meningitis,  332. 
Spinalis  pachymeningitis,  334. 
Splenification,  239. 
Spotted  fever,  26. 
Sprue,  55. 

St.  Anthony's  fire,  49. 
Stomach,  cancer  of,  65. 

diseases  of,  58. 

neuralgia  of,  69, 

remorse  of,  71. 

sjjasm  of,  69. 

washing  out  the,  97. 
Stomatitis,  catarrhal,  52. 

croupous,  53. 


Stomatitis,  diphtheritic,  54- 

erythematous,  52. 

follicular,  53. 

simple,  52. 

ulcerative,  54. 

vesicular,  53. 
Stonepock,  413. 
Stones,  chalk,  160. 
Stools,  chopped  spinach,  88. 
Storm,  electrical,  348. 
Stricture,  intestinal,  96. 
St.  Vitus's  dance,  346. 
Succussion,  192. 
Sudamen,  379. 
Sudamina,  379. 
Sugar,  test  for,  122,  123. 
Summer  complaint,  87. 
Sun  stroke,  329. 
Swamp  fever,  30. 
Sweating,  excessive,  378. 
Sycosis  parasitica,  439. 
Synocha,  16. 
Symptoms,  12. 
Syncope,  305. 
Syrup,  Declat,  42. 


Tabes  dorsalis,  342. 
Taenia  saginata,  98. 

solium,  98. 
Tapeworm,  armed,  98. 

unarmed,  98. 
Temulentia,  323. 
Test  for  albumin,  1 21. 

bile,  122. 

bile  pigment,  122. 

blood,  121. 

chlorides,  I20. 

mucus,  120. 

phosphates,  120. 

pus,  121. 

sugar,  122,  123. 

urates,  119. 

urea,  1 19. 
Tetter,  382. 
Throat,  acute  sore,  198. 

putrid  sore,  144. 
Thrombosis,  cerebral,  299. 
Thrush,  55. 

Thymol  solution,  Morris's,  438. 
Tic-douloureux,  358. 


INDEX. 


46] 


Tincture,  Warburg's,  35, 
Tinea  circinata,  433. 

favosa,  431. 

furfuracea,  371. 

kerion,  336. 

sycosis,  439, 

tonsurans,  436. 

versicolor,  441. 
Tinkling,  metallic,  190. 
Tone,  bandbox,  of  Bamberger,  228. 
Tongue,  strawberry,  40. 
Tonic,  Dr.  A.  H.  Smith's,  363. 

Sir  Erasmus  Wilson's,  373. 
Tonsillitis,  acute,  201. 

catarrhal,  198. 
Tormina,  74. 
Torticollis,  155. 
Toxic  gastritis,  60. 
Trance,  352. 
Treatment,  14. 

abortive,  14. 

expectant,  14. 

preventive,  14. 

restorative,  14. 
Tremens,  delirium,  325. 
Trichinse,  172. 

spiralis,  172. 
Trichinosis,  172. 
Tubercular  meningitis,  310. 
Tuberculosis,  255. 

acute  miliary,  260. 
Tumor,  phantom,  352. 

sebaceous,  376. 
Tumors,  abdominal,  66. 

intracranial,  316, 
Turpentine  in  purpura,  371. 
Turpeth  mineral  in  croup,  209. 
Tyloma,  425. 
Tympanites,  chronic,  106. 
Typhlitis,  93. 
Typho-malarial  fever,  32. 
Typhoid  fever,  19. 
Typhus  fever,  25. 

icterode,  37. 


Ulcer,  duodenal,  64. 

gastric,  63. 

perforating,  63. 
Ulcerative  colitis,  90. 

stomatitis,  54. 


Ulcerosa  gingivitis,  54. 
Uraemia,  acute,  135, 

morphina  in,  136. 
Ursemic  coma,  135. 

convulsions,  135. 
Urates,  test  for,  119. 
Urea,  test  for,  119. 
Uric  acid  diathesis,  161. 

test  for,  119. 
Uridrosis,  377. 
Urine,  118. 

hysterical,  227. 

normal  color,  1 1 8. 

normal  constituents,  118. 

normal  quantity,  1 1 8. 

reaction,  118. 
Urticaria,  396, 


Vaccination,  47. 

Vaccinia,  47. 

Valvular  diseases  of  the  heart,  286. 

diagnosis  of,  292. 
Valvulitis,  277. 
Varicella,  48. 
Variola,  44. 
Varus,  413. 
Verruca,  427. 
Vertigo,  319. 

aural,  319. 

auditory,  319. 

nervous,  319. 

senile,  319. 

stomachic,  58,  319. 
Vesicular  stomatitis,  53. 
Voice  in  disease,  191. 
Vomit,  black,  37. 

coffee  ground,  37. 


Waddle,  the,  341. 
Warburg's  tincture,  34. 
Wart,  427. 

venereal,  428. 
Water  blisters,  404. 

colored  as  a  treatment,  152. 
Wens,  376. 
Wheals,  397 
White  blood,  366. 

cell  blood,  366. 

mouth,  55. 


462 

Whooping-cough,  231. 
Wilson's,  Erasmus,  tonic,  373. 
Worms,  tape,  98. 

round,  100. 

seat,  100. 


INDEX. 

Xeroderma,  429. 
Yellow  fever,  37. 
Zona,  400. 


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and  paper,  handsomely  illustrated  whenever  illustrations 
are  of  use,  and  strongly  bound  in  uniform  style. 

Each  book  is  sold  separately  at  a  remarkably  low 
price,  and  the  immediate  success  of  several  of  the 
volumes  shows  that  the  series  has  met  with  popular 
favor. 

No.  1.    SURGERY.    318  Illustrations. 

Third  Edition. 

A    Manual   of    the    Practice  of    Surgery.     By  Wm.  J. 

Walsh  AM,  m.d.,  Asst.  Surg,  to,  and  Demonstrator  of 

Surg,   in,  St.   Bartholomew's  Hospital,  London,  etc. 

318  Illustrations. 

Presents  the  introductory  facts  in  Surgery  in  clear,  precise 
language,  and  contains  all  the  latest  advances  in  Pathology, 
Antiseptics,  etc. 

"  It  aims  to  occupy  a  position  midway  between  the  pretentious 
manual  and  the  cumbersome  System  of  Surgery,  and  its  general 
character  may  be  summed  up  in  one  word — practical." — The  Medi- 
cal Bulletin. 

"  Walsham,  besides  being  an  excellent  surgeon,  is  a  teacher  in 
its  best  sense,  and  having  had  very  great  experience  in  the 
preparation  of  candidates  for  examination,  and  their  subsequent 
professional  career,  may  be  relied  upon  to  have  carried  out  his 
work  successfully.  Without  following  out  in  detail  his  arrange- 
ment, which  is  excellent,  we  can  at  once  say  that  his  book  is  an 
embodiment  of  modern  ideas  neatly  strung  together,  with  an  amount 
of  careful  organiaation  well  suited  to  the  candidate,  and,  indeed,  to 
the  practitioner." — British  Medical  Journal, 

Price  of  each  Book,  Cloth,  $3.00;  Leather,  $3.60. 


THE   NEW  SERIES  OF  MANUALS. 


No.  2.    DISEASES  OF  ^WOMEN.    150  IlluB. 

NEW     EDITION. 

The  Diseases  of  Women.  Including  Diseases  of  the 
Bladder  and  Urethra.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology  and  Director  of  the  Royal  University 
Clinic  for  Women,  in  Munich.  Second  Edition.  Re- 
vised and  Edited  by  Theophilus  Parvin,  m.d., 
Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  Jefferson  Medical  College.  150  Engrav- 
ings, most  of  which  are  original, 
"  The  book  will  be  a  valuable  one  to  physicians,  and  a  safe  and 

satisfactory  one  to  put  into  the  hands  of  students.     It  is  issued  in  a 

neat  and  attractive  form,  and  at  a  very  reasonable  price." — Boston 

Medical  and  Surgical  Journal . 

No.  3.  OBSTETRICS.  227  Illustrations. 
A  Manual  of  Midwifery.  By  Alfred  Lewis  Galabin, 
M.A.,  M.D.,  Obstetric  Physician  and  Lecturer  on  Mid- 
wifery and  the  Diseases  of  Women  at  Guy's  Hospital, 
London;  Examiner  in  Midwifery  to  the  Conjoint 
Examining  Board  of  England,  etc.     With  227  Illus. 

"This  manual  is  one  we  can  strongly  recommend  to  all  who 
desire  to  study  the  science  as  well  as  the  practice  of  midwifery. 
Students  at  the  present  time  not  only  are  expected  to  know  the 
principles  of  diagnosis,  and  the  treatment  of  the  various  emergen- 
cies and  complications  that  occur  in  the  practice  of  midwifery,  but 
find  that  the  tendency  is  for  examiners  to  ask  more  questions 
relating  to  the  science  of  the  subject  than  was  the  custom  a  few 
years  ago.  *  *  *  The  general  standard  of  the  manual  is  high  ; 
and  wherever  the  science  and  practice  of  midwifery  are  well  taught 
it  will  be  regarded  as  one  of  the  most  important  text-books  on  the 
subj  ect.' ' — London  Practitioner. 

No.  4.    PHYSIOLOGY.    Fifth  Edition. 

321  ILLUSTRATIONS  AND  A  GLOSSARY. 
A  Manual  of  Physiology.  By  Gerald  F.  Yeo,  m.d., 
F.R.c  s..  Professor  of  Physiology  in  King's  College, 
London.  321  Illustrations  and  a  Glossary  of  Terms. 
Fifth  American  from  last  English  Edition,  revised  and 
improved.     758  pages. 

This  volume  was  specially  prepared  to  furnish  students  with  a 
new  text-book  of  Physiology,  elementary  so  far  as  to  avoid  theories 
which  have  not  borne  the  test  of  time  and  such  details  of  methods 
as  are  unnecessary  for  students  in  our  medical  colleges. 

"The  brief  examination  I  have  given  it  was  so  favorable  that  I 
placed  it  in  the  list  of  text-books  recommended  in  the  circular  of  the 
University  Medical  College."— Pr^.  Lewis  A.  Stimson,  m.d., 
3^  East  33d  Street,  New  York, 

Price  of  each  Book,  CSoth,  $3.00;  Leather,  $3.50. 


THE  NEW  SERIES  OF  MANUALS. 


No.  6.    DISEASES  OP  CHILDREN. 

SECOND  EDITION. 
A  Manual.  By  J.  F.  Goodhart,  m.d.,  Phys.  to  the 
Evelina  Hospital  for  Children ;  Asst.  Phys.  to 
Guy's  Hospital,  London,  Second  American  Edition. 
Edited  and  Rearranged  by  Louis  Starr,  m.d.,  Clinical 
Prof,  of  Dis.  of  Children  in  the  Hospital  of  the  Univ. 
of  Pennsylvania,  and  Physician  to  the  Children's  Hos- 
pital, Phila.  Containing  many  new  Prescriptions,  a  list 
of  over  50  Formulas,  conforming  to  the  U.  S.  Pharma- 
copoeia, and  Directions  for  making  Artificial  Human 
Milk,  for  the  Artificial  Digestion  of  Milk,  etc.     Illus. 

"  The  author  has  avoided  the  not  uncommon  error  of  writing  a 
book  on  general  medicine  and  labeling  it  '  Diseases  of  Children,' 
but  has  steadily  kept  in  view  the  diseases  which  seemed  to  be 
incidental  to  childhood,  or  such  points  in  disease  as  appear  to  be  so 
peculiar  to  or  pronounced  in  children  as  to  justify  insistence  upon 
them.  *  *  *  A  safe  and  reliable  guide,  and  in  many  ways 
admirably  adapted  to  the  wants  of  the  student  and  practitioner." — 
American  Journal  of  Medical  Science. 

No.  6.    MATERIA  MEDICA,  PHARMACY, 
PHARMACOLOaY,  AND  THE- 
RAPEUTICS. 

JUST  READY. 
A   Handbook   for   Students.     By  Wm.   Hale  White, 
M.D.,  F.R.C.P.,  etc.,  Physician  to,  and  Lecturer  on  Ma- 
teria Medica,  Guy's  Hospital ;    Examiner  in  Materia 
Medica,  Royal  College   of   Physicians,   London,  etc. 
American  Edition.    Revised  by  Reynold  W.  Wilcox, 
M.A.,  M.D.,  Prof,  of  Clinical  Medicine  at  the  New  York 
Post-Graduate  Medical  School  and  Hospital ;  Assistant 
Visiting  Physician  Bellevue  Hospital.     580  pages. 
In  preparing  this  book,  the  wants  of  the  medical  student  of  to-day 
have  been  constantly  kept  in  view.     The  division  into  several  sub- 
jects, which  are  all  arranged  in  a  systematic,  practical  manner,  will 
be  found  of  great  help  in  mastering  the  whole.     The  work  of  the 
editor  has  been  mainly  in  the  line  of  adapting  the  book  to  the  use 
of  American  students ;  at  the  same  time,  however,  he  has  added 
much  new  material.     Dr.  Wilcox's  long  experience   in  teaching 
and  writing  on  therapeutical  subjects  particularly  fits  him  for  the 
position  of  editor,  and  the  double  authorship  has  resulted  in  mak- 
ing a  very  complete  handbook,  containing  much  minor  useful  in- 
formation that  if  prepared  by  one  man  might  have  been  overlooked. 

Price  of  each  Book.  Cloth,  $3.00  ;  Leather,  $3.60. 


THE   NEW  SERIES  OF  MANUALS. 


No.  7.    MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

THIRD  REVISED  EDITION. 

By  John  J.  Reese,  m.d.,  Professor  of  Medical  Jurispru- 
dence and  Toxicology  in  the  University  of  Pennsyl- 
vania ;  President  of  the  Medical  Jurisprudence  Society 
of  Phila. ;    Third  Edition,  Revised  and  Enlarged. 

"  This  admirable  text-book." — Amer.Jour.  of  Med.  Sciences. 

"  We  lay  this  volume  aside,  after  a  careful  perusal  of  its  pages, 
with  the  profound  impression  that  it  should  be  in  the  hands  of  every 

doctor  and  lawyer.     It  fully  meets  the  wants  of  all  students 

He  has  succeeded  in  admirably  condensing  into  a  handy  volume  all 
the  essential  points." — Cincinnati  Lancet  and  Clinic, 

"  The  book  before  us  will,  we  think,  be  found  to  answer  the  ex- 
pectations of  the  student  or  practitioner  seeking  a  manual  of  juris- 
prudence, and  the  call  for  a  second  edition  is  a  flattering  testimony 
to  the  value  of  the  author's  present  effort.  The  medical  portion 
of  this  volume  seems  to  be  uniformly  excellent,  leaving  little  for 
adverse  criticism.  The  information  on  the  subject  matter  treated 
has  been  carefully  compiled,  in  accordance  with  recent  knowledge. 
The  toxicological  portion  appears  specially  excellent.  Of  that  por- 
tion of  the  work  treating  of  the  legal  relations  of  the  practitioner 
and  medical  witness,  we  can  express  a  generally  favorable  ver- 
dict."— Physician  and  Surgeon,  Ann  Arbor,  Mick. 

No.  8.    DISEASES  OF  THE  EYE.    176  lUus. 

FOURTH  EDITION.    JUST  READY. 

Diseases  of  the  Eye  and  their  Treatment.  A  Handbook 
for  Physicians  and  Students.  By  Henry  R.  Swanzy, 
A.M.,  M.B.,  F.R.C.S.I.,  Surgeon  to  the  National  Eye  and 
Ear  Infirmary ;  Ophthalmic  Surgeon  to  the  Adelaide 
Hospital,  Dublin;  Examiner  in  Ophthalmic  Surgery 
in  the  Royal  University  of  Ireland.  Fourth  Edition, 
Thoroughly  Revised.  176  Illustrations  and  a  Zephyr 
Test  Plate.     500  pages, 

"  Mr.  Swanzy  has  succeeded  in  producing  the  most  intellectually 
conceived  and  thoroughly  executed  resume  of  the  science  within 
the  limits  he  has  assigned  himself.  As  a  'students'  handbook,' 
small  in  size  and  moderate  in  price,  it  can  hardly  be  equaled." — 
Medical  News. 

"  A  full,  clear,  and  comprehensive  statement  of  Eye  Diseases 
and  their  treatment,  practical  and  thorough,  and  we  feel  fully  jus- 
tified in  commending  it  to  our  readers.  It  is  written  in  a  clear  and 
forcible  style,  presenting  in  a  condensed  yet  comprehensive  form 
current  and  modern  information  that  will  prove  alike  beneficial  to 
the  student  and  general  practitioner."— ^tfiz/^A^rw  Practitioner. 

Price  of  each  Book,  Cloth,  $3.00;  Leather,  $3.50. 


6  STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

ANATOMY. 

Morris"  New  Text-Book  on  Anatomy,  600  Specially  En- 
graved Illustrations,  many  of  which  are  printed  in  colors.  Edi- 
ted by  Henry  Morris,  f.r  c.s.,  and  contributed  to  by  many  well- 
known  writers.  Octavo.  Nearly  Ready.  Price  about  6.00 
*:„*  Send  for  Descriptive  Circular  and  Sample  Pages. 

Macalister's  Human  Anatomy.  816  Illustrations.  A  new 
Text-book  for  Students  and  Practitioners,  Systematic  and  Topo- 
graphical, including  the  Embrj-olog^'-,  Histology,  and  Morphology 
of  Man.  With  special  reference  to  the  requirements  of 
Practical  Surgery  and  Medicine.  With  816  Illustrations, 
40c  of  which  are  original.     Octavo.       Cloth,  7.50;  Leather,  8.50 

Ballou's  Veterinary  Anatomy  and  Physiology.  Illustrated. 
By  Wm.  R.  Ballou,  m.u.,  Professor  of  Equine  Anatomy  at  New 
York  College  of  Veterinary'  Surgeons.  29  graphic  Illustrations, 
lamo.  Cloth,  1. 00;  Interleaved  for  notes,  1.25 

Holden's  Anatomy.  A  manual  of  Dissection  of  the  Human 
Body.  Fifth  Edition.  Enlarged,  with  Marginal  References  and 
over  200  Illustrations.     Octavo. 

Bound  in  Oilcloth,  for  the  Dissecting  Room,  $4.50. 

Holden's  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone  and 
its  Development.  With  Lithographic  Plates  and  Numerous  Illus- 
trations. Seventh  Edition.  8vo.  Cloth,  6.00 
Holden's  Landmarks,  Medical  and  Surgical.  4th  ed.  Clo.,  1.25 
Potter's  Compend  of  Anatomy.  Fifth  Edition.  Enlarged. 
16  Lithographic  Plates.     117  Illustrations.     See  Page  14. 

Cloth,  1. 00;  Interleaved  for  Notes,  1.25 

CHEMISTRY. 

Hartley's  Medical  Chemistry.  Second  Edition.  A  text-book 
prepared  specially  for  Medical,  Pharmaceutical,  and  Dental  Stu- 
dents. With  50  Illustrations,  Plate  of  Absorption  Spectra  and 
Glossary  of  Chemical  Terms.    Revised  and  Enlarged.    Cloth, 2.50 

Trimble.  Practical  and  Analytical  Chemistry.  A  Course  in 
Chemical  Analysis,  by  Henry  Trimble,  Prof,  of  Analytical  Chem- 
istry in  the  Phila.  College  of  Pharmacy.  Illustrated.  Fourth 
Edition,  Enlarged.     8vo.  Cloth,  1.50 

Bloxam's  Chemistry,  Inorganic  and  Organic,  with  Experiments. 
Seventh  Edition.  281  Illustrations.  Cloth,  4.50;  Leather,  5.50 
tf^  See  pagex  2  to  3  /or  list  0/  Students'  Manuals . 


STUDENTS'  TEXT-BOOKS  AND  MANUALS,  7 

Chemistry  : — Continued, 

Richter's  Inorganic  Chemistry.  Third  American,  from  Fifth 
German  Edition.  Translated  by  Prof.  Edgar  F.  Smith,  ph.d. 
89  Wood  Engravings  and  Colored  Plate  of  Spectra.     Cloth,  2.00 

Richter's  Organic  Chemistry,  or  Chemistry  of  the  Carbon 
Compounds.     Illustrated.     Second  Edition.  Cloth,  4.50 

Symonds.  Manual  of  Chemistry,  for  the  special  use  of  Medi- 
cal Students.  By  Bkandreth  Symonds,  a.m.,  m.d.,  Asst. 
Physician  Roosevelt  Hospital,  Out- Patient  Department;  Attend- 
ing Physician  Northwestern  Dispensary,  New  York.     Cloth,  2.00 

Leffmann's  Compend  of  Chemistry,    Inorganic  and  Organic. 
Including  Urinary  Analysis.     Third  Edition.     Revised. 
Seepage  i_^.  Cloth,  i. 00;    Interleaved  for  Notes,  1.25 

Leffmann  and  Beam.  Progressive  Exercises  in  Practical 
Chemistry.     i2mo.     Illustrated.  Cloth,  i.oo 

Muter.  Practical  and  Analytical  Chemistry.  Fourth  Edi- 
tion. Revised,  to  meet  the  requirements  of  American  Medical 
Colleges,  by  Prof.  C.  C.  Hamilton.     Illustrated.  Cloth,  2.00 

Holland.  The  Urine,  Common  Poisons,  and  Milk  Analysis, 
Chemical  and  Microscopical,  For  Laboratory  Use.  Fourth 
Edition,  Enlarged.     Illustrated.  Cloth,  i.oo 

Van  Niiys.     Urine  Analysis.     Illus.  Cloth,  2.00 

CHILDREN. 

Goodhart  and  Starr.  The  Diseases  of  Children.  Second 
Edition.  By  J.  F.  Goodhart,  m.d..  Physician  to  the  Evelina 
Hospital  for  Children ;  Assistant  Physician  to  Guy's  Hospital, 
London.  Revised  and  Edited  by  Louis  Starr,  m.d..  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Containing  many  Prescriptions  and  Formulse, 
conforming  to  the  U.  S.  Pharmacopoeia,  Directions  for  making 
Artificial  Human  Milk,  for  the  Artificial  Digestion  of  Milk,  etc. 
Illustrated.  Cloth,  3.00;  Leather,  3.50 

Hatfield.  Diseases  of  Children.  By  M.  P.  Hatfield,  m.d.. 
Professor  of  Diseases  of  Children,  Chicago  Medical  College. 
Colored  Plate.     i2mo.  Cloth,  i.oo;   Interleaved,  1.25 

Starr.  Diseases  of  the  Digestive  Organs  in  Infancy  and 
Childhood.  With  chapters  on  the  Investigation  of  Disease, 
and  on  the  General  Management  of  Children.  By  Louis  Starr, 
M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Univer- 
sity of  Pennsylvania.  Illus.  Second  Edition..  Cloth,  2.25 
^^  See  pages  14  and  15  for  list  of?  Quiz- Comp  ends? 


8  STUDENTS'   TEXT-BOOKS  AND   MANUALS. 

DENTISTRY. 

Fillebrown.    Operative  Dentistry.    330  lUus.  Cloth,  2.50 

Flagg's  Plastics  and  Plastic  Filling.     4th  Ed.         Cloth,  4.00 
Gorgas.     Dental  Medicine.     Fourth  Edition.  Cloth,  3.50 

Harris.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology',  Pathology,  Therapeutics,  Dental  Surgery 
and  Mechanism.  Twelfth  Edition.  Revised  and  enlarged  by 
Professor  Gorgas.  1028  Illustrations.  Cloth,  7.00  ;  Leather,  8.00 
Richardson's  Mechanical  Dentistry.  Fifth  Edition.  569 
Illustrations.     8vo.  Cloth,  4.50;  Leather,  5.50 

Sewill.     Dental  Surgery.     200  Illustrations.     3d  Ed.   CIo.,  3.00 
Taft's  Operative  Dentistry.    Dental  Students  and  Practitioners. 
Fourth  Edition.     100  Illustrations.        Cloth,  4.25  ;  Leather,  5.00 
Talbot.      Irregularities   of  the   Teeth,  and  their  Treatment. 
Illustrated.     Svo.     Second  Edition.  Cloth,  3.00 

Tomes'  Dental  Anatomy.     Third  Ed.      191  lUus.      Cloth,  4.00 
Tomes'  Dental   Surgery.      3d  Edition.     292  lUus.    Cloth,  5.00 
Warren.    Compend  of  Dental  Pathology  and  Dental  Medi- 
cine,    Illustrated.  Cloth,  i.oo;  Interleaved,  1.25 

DICTIONARIES. 

Gould's  New  Medical  Dictionary.  Containing  the  Definition 
and  Pronunciation  of  all  words  in  Medicine,  with  many  useful 
Tables  etc.    J^  Dark  Leather,  3.25  ;  J^  Mor.,  Thumb  Index,  4.25 

Gould's  Pocket  Dictionary,  12,000  Medical  Words  Pro- 
nounced and  Defined.  Containing  many  Tables  and  an 
Elaborate  Dose  List.     Thin  64mo.    Jtist  Ready.     Leather,  1.25 

Harris'  Dictionary  of  Dentistry.  Fifth  Edition.  Completely 
revised  by  Prof.  Gorgas.  Cloth,  5.0c;   Leather,  6.00 

Cleaveland's  Pronouncing  Pocket  Medical  Lexicon.  Small 
pocket  size.  Cloth,  red  edges  .75  ;  pocket-book  style,  i.oo 

Longley's  Pocket  Dictionary.  The  Student's  Medical  Lexicon, 
giving  Definition  and  Pronunciation,  with  an  Appendix  giving 
Abbreviations  used  in  Prescriptions,  Metric  Scale  of  Doses,  etc. 
24™o-  Cloth,  I.oo;  pocket-book  style,  1,25 

EYE. 

Hartridge  on  Refraction.     5th  Edition.     Illus.  Cloth,  2.00 

Swanzy.     Diseases  of  the  Eye  and  their  Treatment,     176 

Illustrations.     Fourth  Edition.  Cloth,  3  00;   Leather,  3.50 

Fox  and  Gould.  Compend  of  Diseases  of  the  Eye  and 
Refraction.     2d  Ed.     Enlarged.     71  Illus.     39  Formulae. 

Cloth,  1.00  ;  Interleaved  for  Notes,  1.25 

HfS"  See  pages  2  to  S  /'>'''  '"''  ^  Students'  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.  9 

ELECTRICITY. 

Bigelow.    Plain  Talks  on  Medical  Electricity.  Cloth,  i.oo 

Mason's  Compend  of  Medical  Electricity.  Cloth,  i.oo 

Steavenson  and  Jones.     Medical  Electricity.  A  Practical 

Handbook.    Just  Ready,     Illustrated.     i2mo.  Cloth,  2.50 

HYGIENE. 

Coplin  and  Bevan.  Practical  Hygiene.  By  W.  M.  L.  Cop- 
lin.  Adjunct  Professor  of  Hj'giene,  Jefferson  Medical  College, 
Philadelphia,  and  Dr.  D.  Bevan.     Illustrated.  In  Press, 

Parkas'  (Ed.  A.)  Practical  Hygiene.  Seventh  Edition,  en- 
larged.    Illustrated.     8vo.  Cloth,  4.50 

Parkes'  (L,  C.)  Manual  of  Hygiene  and  Public  Health. 
Second  Edition.     i2mo.  Cloth,  2.50 

Wilson's    Handbook  of   Hygiene   and   Sanitary    Science. 

Seventh  Edition.     Revised  and  Illustrated.  Cloth,  3.25 

MATERIA  MEDICA  AND  THERAPEUTICS. 

Potter's  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  Writing.  Fifth  Edition,  revised  and  improved. 
See pag^e  ij.  Cloth,  i.oo;   Interleaved  for  Notes,  1.25 

Davis.  Essentials  of  Materia  Medica  and  Prescription 
Writing.  By  J.  Aubrey  Davis,  m.d..  Demonstrator  of  Obstet- 
rics and  Quiz-Master  on  Materia  Medica,  University  of  Penn- 
sylvania.    i2mo.     Interleaved.  Net,  1.50 

Biddle's  Materia  Medica.  Eleventh  Edition.  By  the  late 
John  B.  Biddle,  m.d.  Revised  by  Clement  Biddle,  m.d.,  8vo, 
illustrated.  Cloth,  4.25;  Leather,  5.00 

Potter.  Handbook  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.  Including  Action  of  Medicines,  Special  Thera- 
peutics, Pharmacology,  etc.  By  Saml.  O.  L.  Potter,  m.d., 
M.R.c.p.  (Lond.),  Professor  of  the  Practice  of  Medicine  in 
Cooper  Medical  College,  San  Francisco.  Third  Revised  and 
Enlarged  Edition.     8vo.  Cloth,  4.00;  Leather,  5.00 

White  and  Wilcox.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  A  Handbook  for  Students. 
By  Wm.  Hale  White,  m.d.,  f.r.c.p.,  etc.,  Physician  to  and 
Lecturer  on  Materia  Medica,  Guy's  Hospital.  Revised  by 
Reynold  W.  Wilcox,  m.d..  Professor  of  Clinical  Medicine  at  the 
New  York  Post  Graduate  Medical  School,  Assistant  Physician 
Bellevue  Hospital,  etc.    American  Edition.    Clo,,  3.00  ;  Lea.,  3.50 

■  See  pages  14  and  /j  for  list  of  ?  Quiz-  Cotnpends  ? 


10        STUDENTS'   TEXT-BOOKS   AND   MANUALS. 

MEDICAL  JURISPRUDENCE. 

Reese.  A  Text-book  of  Medical  Jurisprudence  and  Toxi- 
cology. By  John  J.  Reese,  M.D.,  Professor  of  Medical  Juris- 
prudence and  Toxicology  in  the  Medical  Department  of  the 
University  of  Pennsylvania  ;  Physician  to  St.  Joseph's  Hospital. 
Third  Edition.  Cloth,  3.00;  Leather,  3.50 

NERVOUS  DISEASES. 

Gowers.  Manual  of  Diseases  of  the  Nervous  System. 
A  Complete  Text-book.  By  William  R.  Gowers,  m.d..  Prof. 
Clinical  Medicine,  University  College,  London.  Physician  to 
National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged,  and  in  many  parts  Rewritten. 
With  many  new  Illustrations.  Octavo. 
Vol.  L      Diseases  of  the  Nerves  and  Spinal  Cord.      616 

pages.  Cloth,  3.50 

Vol.   II.     Diseases   of   the    Brain   and   Cranial   Nerves. 

General  and  Functional  Diseases.  Nearly  Ready. 

Ormerod.  Diseases  of  Nervous  System,  Student's  Guide  to. 
By  J.  A.  Ormerod,  m.d.,  O.xon.,  f.k.c.p.  (London),  Member  Path- 
ological. Clinical,  Ophthalmological,  and  Neurological  Societies, 
Physician  to  National  Hospital  for  Paralyzed  and  Epileptic  and 
to  City  of  London  Hospital  for  Diseases  of  the  Chest,  Demon- 
strator of  Morbid  Anatomy,  St.  Bartholomew's  Hospital,  etc. 
With  75  Wood  Engravings.  Cloth,  2.00 

OBSTETRICS  AND   GYNiECOLOGY. 

Davis.  A  Manual  of  Obstetrics.  By  Edw.  P.  Davis,  Dem- 
onstrator of  Obstetrics,  Jefferson  Medical  College,  Philadelphia. 
Colored  Plates,  and  130  other  Illustrations.     lamo.      Cloth,  2.00 

Byford.  Diseases  of  Women.  The  Practice  of  Medicine  and 
Surgery,  as  applied  to  the  Diseases  and  Accidents  Incident  to 
Women.  By  W.  H.  Byford,  a.m.,  m.d..  Professor  of  Gynaecology 
in  Rush  Medical  College  and  of  Obstetrics  in  the  Woman's  Med- 
ical College,  etc.,  and  Henry  T.  Byford,  m.d.,  Surgeon  to  the 
Woman's  Hospital  of  Chicago.  Fourth  Edition.  Revised  and 
Enlarged.  306  Illustrations,  over  loc  of  which  are  original. 
Octavo.     832  pages.  Cloth,  5.00;  Leather,  6.00 

Lewers'  Diseases  of  Women.  A  Practical  Text-book.  139 
Illustrations.     Second  Edition.  Cloth,  2.50 

Parvin's  WincUel's  Diseases  of  W^omen.  Second  Edition. 
Including  a  Section  on  Diseases  of  the  Bladder  and  Urethra. 
150  lUus.     Revised.     Seepages.  Cloth,  3.00;  Leather,  3.50 

Morris.    Compend  of  Gynaecology.    Illustrated.     Cloth,  i. 00 

■Winckel's  Obstetrics.  A  Text-book  on  Midwifery,  includ- 
ing the  Diseases  of  Childbed.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology,  and  Director  of  the  Royal  University  Clinic  for 
Women,  in  Munich.  Authorized  Translation,  by  J.  Clifton 
Edgar,  m.d..  Lecturer  on  Obstetrics,  University  Medical  Col- 
lege, New  York,  with  nearly  20^^  handsome  Illustrations,  the 
majority  of  which  are  original.    8vo.     Cloth,  6.00;   Leather,  7.00 

4^  See  pagei  2  to  s/or  iist  0/ New  Manuals. 


STUDENTS'   TEXT-BOOKS   AND   MANUALS.         11 


Obstetrics  and  Gynaecology  : — Continued. 
Landis'  Compend    of   Obstetrics.      Illustrated.    4th  Edition, 
Enlarged.  Cloth,  i.oo;   Interleaved  for  Notes,  1.25 

Galabin's   Midwifery.      By  A.    Lewis   Galabin,   m.d.,  f.r.c.p. 

227  Illustrations.     See  page  3.  Cloth,  3.00;  Leather,  3.50 

PATHOLOGY,  HISTOLOGY,  ETC. 

AVethered.     Medical   Microscopy.  By  Frank  J.  Wethered, 

M.D.,  M.R.c.p.     98  Illustrations.  Cloth,  2,50 

Bowlby.     Surgical   Pathology  and  Morbid  Anatomy,  for 

Students.     135  Illustrations.     i2mo.  Cloth,  2.00 

Gilliam's  Essentials  of  Pathology.  A  Handbook  for  Students. 
47  Illustrations.     i2mo.  Cloth,  2.00 

Virchow's  Post-Mortem  Examinations.     3d  Ed.    Cloth,  1.00 

PHYSICAL  DIAGNOSIS. 

Fenwick.  Student's  Guide  to  Physical  Diagnosis.  7th 
Edition.     117  Illustrations.     lamo.  Cloth,  2.25 

Tyson's  Student's  Handbook  of  Physical  Diagnosis.  Illus- 
trated.    i2mo.  Cloth,  1.25 

PHYSIOLOGY. 

Yeo's  Physiology.  Fifth  Edition.  The  most  Popular  Stu- 
dents' Book.  By  Gerald  P'.  Yeo,  m.d.,  f.r.c.s..  Professor  of 
Physiology  in  King's  College,  London.  Small  Octavo.  758 
pages.  321  carefully  printed  Illustrations.  With  a  Full 
Glossary  and  Index.     See  page  3,  Cloth,  3.00;  Leather,  3.50 

Brubaker's  Compend  of  Physiology.  Illustrated.  Sixth 
Edition.  Cloth,  1.00;    Interleaved  for  Notes,  1.25 

Kirke's  Physiology.  New  13th  Ed.  Thoroughly  Revised  and 
Enlarged.     502  IlliLstrations,  some  of  which  are  printed  in  colors. 

Cloth,  4.00;  Leather,  5.C0 

Landois'  Human  Physiology.  Including  Histology  and  Micro- 
scopical Anatomy,  and  with  special  reference  to  Practical  Medi- 
cine. Fourth  Edition.  Translated  and  Edited  by  Prof.  Stirling. 
845  Illustrations.  Cloth,  7.00;  Leather,  8.00 

"  With  this  Text-book  at  his  command,  no  student  could  fail  in 

his  examination." — Lancet. 

Sanderson's  Physiological  Laboratory.  Being  Practical  Ex- 
ercises for  the  Student.     350  Illustrations.     8vo.  Cloth,  5.00 

PRACTICE. 

Taylor.  Practice  of  Medicine.  A  Manual.  By  Frederick 
Taylor,  m.d.,  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London  ;  Physician  to  Evelina  Hospital  for  Sick  Chil- 
dren, and  Examiner  in  Materia  Medica  and  Pharmaceutical 
Chemistry,  University  of  London.  Cloth,  2.00;   Leather,  2.50 

VS'  See  pages  14  and  jj /or  list  0/  ?  Quiz- Comp ends  f 


12        STUDENTS'   TEXT-BOOKS  AND  MANUALS. 


Practice  : —  Continued. 

Roberts'  Practice.  New  Revised  Edition.  A  Handbook 
of  the  Theor}'  and  Practice  of  Medicine.  By  Frederick  T. 
Roberts,  m.d.,  m.r.c.p.,  Professor  of  Clinical  Medicine  and 
Therapeutics  in  University  College  Hospital,  London.  Seventh 
Edition.     Octavo.  Cloth,  5.50  ;  Sheep,  6.50 

Hughes.  Compend  of  the  Practice  of  Medicine.  4th  Edi- 
tion.    Two  parts,  each.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

P.\RT  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 
Kidneys,  etc.,  and  General  Diseases,  etc. 

Part  ii. — Diseases  of  the  Respiratory  System,  Circulatory 
System,  and  Ner%'ous  System;  Diseases  of  the  Blood,  etc. 

Physicians' Edition.    Fourth  Edition.    Including  a  Section 
on  Skin  Diseases.   With  Index,    i  vol.  Full  Morocco,  Gilt,  2.50 

From  John  A.  Robinson,  M.D.,  Assistant  to  Chair  0/  Clinical 
Medicine ,  now  Lecturer  on  Materia  Medica,  Rush  Medical  Col- 
lege, Chicago. 
"  Meets  with   my   hearty  approbation   as   a   substitute  for   the 

ordinar}'^  note  books  almost  universally  used  by  medical  students. 

It  is  concise,  accurate,  well  arranged,  and  lucid,     .     .     .    just  the 

thing  for  students  to  use  while  studying  physical  diagnosis  and  the 

more  practical  departments  of  medicine." 

PRESCRIPTION   BOOKS. 

Wythe's  Dose  and  Symptom  Book.  Containing  the  Doses 
and  Uses  of  all  the  principal  Articles  of  the  Materia  Medica,  etc. 
Seventeenth  Edition.  Completely  Revised  and  Rewritten.  Jt^t 
Ready.     32mo.  Cloth,  i. 00;    Pocket-book  style,  1.25 

Pereira's  Physician's  Prescription  Book.  Containing  Lists 
of  Terms,  Phrases,  Contractions,  and  Abbreviations  used  in 
Prescriptions,  Explanatory'  Notes,  Grammatical  Construction  of 
Prescriptions,  etc.,  etc.  By  Professor  Jonathan  Pereira,  m.d. 
Sixteenth  Edition.     32mo.     Cloth,  i. 00;   Pocket-book  style,  1.25 

PHARMACY. 
Stewart's  Compend  of  Pharmacy.     Based  upon  Remington's 
Text-book  of  Pharmacy.      Third  Edition,  Revised.     With  new 
Tables,  Index,  Etc.  Cloth,  i.oo  ;  Interleaved  for  Notes,  1.25 

Robinson.  Latin  Grammar  of  Pharmacy  and  Medicine. 
By  H.  D.  Robinson,  ph.d..  Professor  of  Latin  Language  and 
Literature,  University  of  Kansas,  Lawrence.  With  an  Intro- 
duction by  L.  E.  Sayre,  ph.g.,  Professor  of  Pharmacy  in,  and 
Dean  of,  the  Dept.  of  Pharmacy,  University  of  Kansas.     i2mo. 

Cloth,  2.00 

SKIN  DISEASES. 
Anderson,  (McCall)  Skin  Diseases.     A  complete   Text-book, 
with    Colored    Plates   and   numerous    Wood    Engravings.    8vo. 

Cloth,  4.50;  Leather,  5.50 

Van  Harlingen  on  Skin  Diseases.  A  Handbook  of  the  Dis- 
eases of  the  Skin,  their  Diagnosis  and  Treatment  (arranged  alpha- 
betically). By  Arthur  Van  Harlingen,  m.u.,  Clinical  Lecturer 
on  Dermatology,  Jefferson  Medical  College;  Prof,  of  Diseases  of 
the  Skin  in  the  Philadelphia  Polyclinic.  2d  Edition.  Enlarged. 
V/ith  colored  and  other  plates  and  illustrations.  72mo.  Cloth,  2.50 
9f^  See  pages  2  to  S  for  list  0/ New  Manuals. 


STUDENTS'   TEXT-BOOKS  AND  MANUALS.        13 
SURGERY  AND    BANDAGING. 

Moullin's  Surgery.  500  Illustrations  (some  colored),  200  of 
which  are  original.     2d  Ed.        Cloth,  net  7.00;  Leather,  net  8.00 

Jacobson.  Operations  in  Surgery.  A  Systematic  Handbook 
for  Physicians,  Students,  and  Hospital  Surgeons.  By  W.  H.  A. 
Jacobson,  b.a.  Oxon.,  f.r.c.s.  Eng. ;  Ass't  Surgeon  Guy's  Hos- 
pital ;  Surgeon  at  Royal  Hospital  for  Children  and  Women,  etc. 
199  Illustrations.     1006  pages.     8vo.      Cloth.  5.00;  Leather,  6.00 

Heath's  Minor  Surgery,  and  Bandaging.  Ninth  Edition.  142 
Illustrations.     60  Formulae  and  Diet  Lists.  Cloth,  2.00 

Horwitz's    Compend    of    Surgery,    Minor     Surgery    and 
Bandaging,    Amputations,    Fractures,    Dislocations,   Surgical 
Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential 
Diagnosis  and  Treatment.     By  Orville  Horwitz,  b.s.,  m.d.. 
Demonstrator  of  Surgery,  Jefferson  Medical  College.    4th  edition. 
Enlarged  and  Rearranged.     136   Illustrations   and   84  Formulae. 
i2mo.         Cloth,  i.oo;  Interleaved  for  the  addition  of  Notes,  1.25 
_***The  new  Section  on  Bandaging  and  Surgical  Dressings  con- 
sists  of  32   Pages  and   41    Illustrations.     Every   Bandage  of   any 
importance   is   figured.      This,  with    the   Section   on   Ligation  of 
Arteries,  form.s  an  ample  Text-book  for  the  Surgical  Laboratory. 

Walsham.  Manual  of  Practical  Surgery.  Third  Edition. 
By  Wm.  J.  Walsham,  m.d.,  f.r.c.s.,  Asst.  Surg,  to,  and  Dem- 
of  Practical  Surg,  in,  St.  Bartholomew's  Hospital ;  Surgeon  to 
Metropolitan  Free  Hospital,  London.  With  318  Engravings. 
See  page  2.  Cloth,  3.00 ;  Leather,  3.50 

URINE,  URINARY   ORGANS,  ETC. 

Holland.  The  Urine,  and  Common  Poisons  and  The 
Milk.  Chemical  and  Microscopical,  for  Laboratory  Use.  Illus- 
trated.    Fourth  Edition.     i2mo.     Interleaved.  Cloth,  i.oo 

Ralfe,  Kidney  Diseases  and  Urinary  Derangements.  42  Illus- 
trations.    i2mo.     572  pages.  Cloth,  2.75 

Marshall  and  Smith.  On  the  Urine.  The  Chemical  Analysis  of 
the  Urine.  By  John  Marshall,  m.d..  Chemical  Laboratory,  Univ. 
of  Penna;  and  Prof.  E.  F.  Smith,  ph. d.  Col.  Plates.    Cloth,  i.oo 

Memminger.     Diagnosis  by  the  Urine.     Illustrated. 

Cloth,  I.oo 

Tyson.  On  the  Urine.  A  Practical  Guide  to  the  Examination 
of  Urine.  With  Colored  Plates  and  Wood  Engravings.  7th  Ed. 
Enlarged.    i2mo.  Cloth,  1.50 

Van  Niiys,  Urine  Analysis.    lUus.  Cloth,  2.00 

VENEREAL  DISEASES. 

Hill  and  Cooper.  Student's  Manual  of  Venereal  Diseases, 
with  Formulae.     Fourth  Edition.     i2mo.  Cloth,  i.oo 

See  pages  14  and  ij  for  list  of  ?  Quiz- Contp ends  f 


POUIZ-COMPENDS? 

The  Best  Compends  for  Students'  Use 
in  the  Quiz  Class,  and  when  Pre- 
paring for  Examinations. 

Compiled  in  accordance  with  the  latest  teachings  of  promi- 
nent Lecturers  and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical,  and  exhaustive 
set  of  manuals,  containing  information  nowhere  else  col- 
lected in  such  a  condensed,  practical  shape.  Thoroughly 
up  to  the  times  in  every  respect,  containing  many  new 
prescriptions  and  formulae,  and  over  two  hundred  and 
rifty  illustrations,  many  of  which  have  been  drawn  and 
engraved  specially  for  this  series.  The  authors  have  had 
large  experience  as  quiz-masters  and  attaches  of  colleges, 
with  exceptional  opportunities  for  noting  the  most  recent 
advances  and  methods. 

Cloth,  each  $i.cx3.     Interleaved  for  Notes,  $1.25. 

No.  I.  HUMAN  ANATOMY,  "Based  upon  Gray."  Fifth 
Enlarged  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  16  Lithograph  Plates,  New 
Tables,  and  117  other  Illustrations.  By  Samuel  O.  L. 
Potter,  m.a.,  m.d.,  m.r.c.p.  (Lend.),  late  A.  A.  Surgeon  U.  S. 
Army,  Professor  of  Practice,  Cooper  Aledical  College,  San  Fran- 
cisco. 

Nos.  2  and  3.  PRACTICE  OF  MEDICINE.  Fourth  Edi- 
tion. Hy  Daniel  E.  Hughes,  m.u.,  Demonstrator  of  Clinical 
Medicine  in  Jefferson  Medical  College, Philadelphia.  In  two  parts. 

Part  I. — Continued,  Eruptive,  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 
Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (including  Phy- 
sical Diagnosis),  Circulatory  System,  and  Nervous  System;  Dis- 
eases of  the  Blood,  etc. 

%*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon 
the  Practice  of  Medicine,  containing  the  Synonyms,  Definitions, 
Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each 
disease,  and  including  a  number  of  prescriptions  hitherto  unpub- 
lished. 
No.    4.     PHYSIOLOGY,    including    Embryology.    Sixth 

Edition.    By  Albert  P.  Brubakek,  m.u.,  Prof,  of  Physiology, 

Penn'a  College  of  Dental  Surgery  ;   Demonstrator  of  Physiology 

in  Jefferson  Medical  College,  Philadelphia.    Revised,  Enlarged, 

with  new  Illustrations. 

No.  5.  OBSTETRICS.  Illustrated.  Fourth  Edition.  By 
Henry  C  Lanuis,  m.d.,  Prof,  of  Obstetrics  and  Diseases  of 
Women  in  Starling  Medical  College,  Columbus,  O.  Revised 
Edition.     New  Illustrations. 


BLAKISTON'S  ?  QUIZ-COMPENDS  ? 

No,  6.  MATERIA  MEDICA,  THERAPEUTICS,  AND 
PRESCRIPTION    WRITING,     Fifth   Revised   Edition. 

With  especial  Reference  to  the  Physiological  Action  of  Drugs, 
and  a  complete  article  on  Prescription  Writing.  Based  on  the 
Last  Revision  of  the  U.  S.  Pharmacopoeia,  and  including  many 
unofficiual  remedies.  By  Samuel  O.  L.  Potter,  m.a.,  m.d., 
M.R.c.P.  (Lond.),  late  A.  A.  Surg.  U.  S.  Army ;  Prof,  of  Practice, 
Cooper  Medical  College,  San  Francisco.  Improved  and  Enlarged, 
with  Index. 
No.  7.  GYN.ffiCOLOGY.  A  Compend  of  Diseases  of  Women. 
By  Henry  Morki?,  m.d.,  Demonstrator  of  Obstetrics,  Jefferson 
Medical  College,  Philadelphia.      45  Illustrations. 

No.  8.     DISEASES  OF  THE  EYE  AND  REFRACTION, 

including  Treatment  and  Surgery.  By  L.  Webster  Fox,  m.d.. 
Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Med- 
ical College,  etc.,  and  Geo.  M.  Gould,  m.d.  71  Illustrations,  39 
Formulas.     Second  Enlarged  and  improved  Edition.    Index. 

No.  9,  SURGERY,  Minor  Surgery  and  Bandaging.  Illus- 
trated. Fourth  Edition.  Including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations,  and  other  operations;  Inflam- 
mation, Suppuration,  Ulcers,  Syphilis,  Tumors,  Shock,  etc. 
Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d.. 
Demonstrator  of  Surgery,  Jefferson  Medical  College.  Revised 
and  Enlarged.     84  Formulse  and  136  Illustrations. 

No.  10.  CHEMISTRY.  Inorganic  and  Organic.  For  Medical 
and  Dental  Students.  Including  Urinary  Analysis  and  Medical 
Chemistry.  By  Henry  Leffmann,  m.d.,  Prof,  of  Chemistry  in 
Penn'a  College  of  Dental  Surgery,  Phila.  Third  Edition,  Revised 
and  Rewritten,  with  Index. 

No.  II.  PHARMACY.  Based  upon  "  Remington's  Text-book 
of  Pharmacy."  By  F.  E.  Stewart,  m.d.,  ph.g.,  Quiz-Master 
at  Philadelphia  College  of  Pharmacy.     Third  Edition,  Revised. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOL- 
OGY. 29  Illustrations.  By  Wm.  R.  Ballou,  m.d.,  Prof,  of 
Equine  Anatomy  at  N.  Y.  College  of  Veterinary  Surgeons. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDI- 
CINE. Containing  all  the  most  noteworthy  points  of  interest 
to  the  Dental  student.  By  Geo.  W.  Warren,  d.d.s..  Clinical 
Chief,  Penn'a  College  of  Dental  Surgery,  Philadelphia.     Illus. 

No,  14.  DISEASES  OF  CHILDREN.  By  Dr.  Marcus  P. 
Hatfield,  Prof,  of  Diseases  of  Children,  Chicago  Medical 
College.     Colored  Plate. 

Bound  in  Cloth,  $1.    Interleaved,  for  the  Addition  of  Kotes,  $1.25. 


These  books  are  constantly  revised  to  keep  up  with 
the  latest  teachings  and  discoveries^  so  that  they  contain 
all  the  new  methods  and  principles.  No  series  of  books 
are  so  complete  in  detail,  concise  in  language^  or  so  well 
printed  and  bound.  Each  one  for7ns  a  coviplete  set  of 
notes  upon  the  subject  under  consideration. 

Illustrated  Descriptive  Circular  Free. 


JUST  PUBLISHED. 


GOULD'S  NEW 

Medical  Dictionary 


COMPACT. 
COxN'CISE. 
PRACTICAL. 
ACCURATE. 


QS I  COMPREHENSIVE 
n^       UP  TO  DATE. 


It  contains  Tables  of  the  Arteries,  Bacilli,  Gan- 
glia,   Leucomaines,    Micrococci,    Muscles, 
Nerves,    Plexuses,    Ptomaines,    etc., 
etc.,  that  will  be  found  of  great 
use   to   the    student. 

Small  octavo,  520  pages,  Half-Dark  Leather,      .     ^3.25 
With  Thumb  Index,  Half  Morocco,  marbled  edges,  4.25 


From  J.  M.  DaCOSTA,  M.  D.,  Professor  of  Practice  and 
Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"/yi»d  it  an  excellent  -work,  doing  credit  to  the  learning  and 
discrimination  of  the  author." 

V  Sample  Pages  free. 


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